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HomeMy WebLinkAbout1288A (6) � •. WORKERS'COMFEI3SAT10ND£CLARAi70N 96w6f>Y APPLICATION FOR PLUMBING PERMIT r,� � [ hereby aPfirm that I have a certificete af consent [o seif ce eu(s-■ol insure,or a certificate ot Workers'Compensation Insurance,or � � a certifiad copy thereof(Sec.38p0,Lab.C.) COUNTY QF LOS ANGELES 9W LOtNG AND SAEE7Y ___ Policy No. Compan � � I � Certitied copy is hereby furrtished. FOR AVPIICANT TO FILL IN(PRINT OR TYPE) � ��-- �VILD�NG p • NlJMBEF FIXTURE OR iTEM • FEE . A�ORESS_ ���-J � - � Certified copy is filed with tl unty bylldtny inspection � �'j -����� depit t. 6 � IOCAlfTY . .��a '. . .�. - WA7ER CLOSET Date Applicyni �EAREST _ / _ - � � BATH TUB CROSS 57. -GC,/Cm��l � CERTIFSCATE OF BX�MPT10 PROM WORKERS' . ��� �'��-���� "- �� �-����- �� ��� �� . ........... .... . .._. . ... . �.... COMPENSATION[NSURANCE sffaWEp OWNER . LAVATQRY MA�L .�....-- '-...._....._ . . ... . . y (This section need no[ be wmpleted if tEte work involved � ADDRESS " �- by the pe:mit is for one hundred dollars (5100)ai less.) S1NK ��TY _ - 're�.NO f/S"la U , f certify that in the perfoimancC of the work for which this OISHWASHEH � I WNTRACTOR . permit is iasund,I shall not employ any person in any manner . � 0 i w as to bscome subject to the Wwkorn'CompensaHon Eaws. CLOTHE5 WASNER _ . � --- �-��-'�� -�"-- ��""��" � v i co AD�RESff----------- Uate Applicant SWIMMING POOE HECEPTOfl d � NOTICE TO APY4ICANi:If,afier maktng fhis Certifica[e of CtTY '� TEL NO. • � i � tixemplion, you should become subjact to the Workers' LAWN5PRfNKLERSYSTEM S7A7E � - LIC. — J Compensation provisions of the Labar Code,you muat forth- � � LICENSE NO. ��� CLA55 �"�� ! with comply with such provisions or this pncrtit shali be WATER HEATER � _ deemed revoked. G9.5 SYSTEM OUTLETS � O15TRICT NO. PFLO ESS6D 8Y � � ___. _ __ __ i LICENSED CONTRAL'TURS DECLAAATION- - � -- - - '" �-----�--— ��� • 4�-<-r-tr- DtJTlETS OVER--— i �� 5 PER SVSTEM - 1 S hereby afficm thni l eai licensed�oder groviniauof Chaptet - ---- --------"---�-- ` 9 commencin with Srttion 90001 of Division 3 af the Busi- - - - FINA � � ' ness and Vrotessions Code,aIId mY licence isin Fulk iMce uid OATE - _ ..�tj �'�.. .vALI�AZ�ON. _ .. � i e€fect. /� / j i License Numb � �" Lic.Class �~�• _ ....... .. . . . BY A ; ) � `Con[raciar Date J/+ � � I am exempt rom tAe licensing ttUui[emertts as!am a Plan check fee � licensed architeM or a.regis[ered prufesseonal..�n�inecr pLUMBING PEHFAIT 4SSUING FEE$ � acting iw mY P�pfz��at-:capasi3Y (��+�zOSt, B�� ' iness xnd!'rofessions Code). TOTAL FBE � � �1288A Lic.ur Rng.No. � Date_ P�an check epplicant #. . . . .5. HOME OWN�R-BtJ[LDEft aEELARATtOM Name . __ ._ - � ---.._ ---�-—_. . - � • •j 2..�.6 _ I hereby affirm that I am ezempt fcom the ContractoPs Address "- � � . License L•.w tor the fullowing reason (Seotion 9031.5,Busi- p�tv Tel.No. • • �1 2 5 G� . ness and Profassions Code): _ � [,as uwnec of the pcaperty,am ¢zclUbiv¢ly contracting . C�,� g'�G G with licensed tontractors to construct the project , - � (Sedion 7044,Husiness and Professions Code). . - � ' ' '. � .. • ! CONSTRUCTIUN LENDING AGENCY � � I h I hereby afPirm thet thece is a construction lending agency for the performance of the work for which thia permit is �issued(Sec.309�.Civ.C.). i Len4er's Name ' � �Lender's Address ! I certify that 1 have resd this appiication and state that ihe �above information is correct.]agree to comply with all County ', SEE REVERSE FUR EXPLANA'IORY[,ANGUAUE ordiiianres and Stnte laws regulating Plumbing, and hereby �authorize representatives of this County to entec upon the ' ;above- en' ned pro erty(or inspection urpo s. � / / �.Z � Signatur ermi:.cc Date � .i y ; � • � y w" '�s � - �r v-.�v �.,� �°,� ° -i x Y � Qe� _ a °icS �l;�x ti �o^ L� Ga.°'� . y' S�' `o� v � = 3 � C oi � o � ,i, ' „T, �' �, ^ y w,v p, .. � C �r r. o_, � o c''^° o"� °' °" � 3 �� �5 � °' � '' ti .. c, c• r ncvg��; a. vK� =n^.:,c y�� c �.=�=�s `� . v�' � � o, � � o - u �- o C r o �� M � S..�s K� O C v �.,i� o';�z= ,C . . 7 � � �=��� c+a �+�" ..�� c.� �' '3 ._ . v'� �� .. a � d. n «. c'�ga Q `.�'G c,.�' �'�-' d c G� o s.� a � �w ~ �s„�v . ti iwn bi�C � „J„ '. '`. O w • 4.-. ^"�„ U `� E G � �'C�� v G G`c5 �n. 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