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HomeMy WebLinkAbout1752A Js.� . . � µ.v:;ce� .:�a,...a . .... . . .,.;»��,:v�a ,,.xw,,:;a+w .,<<•w�s,�.�sa^t�.a�v+�;:'�ar�e...,wun.o � wo.�.w, n ,y,s«w...,...-�,. . . . ...__.,-.._.,e_ WORKhRS'COMPENS4TIONDECLARAI'ION ]6A66]A qPPLICATION FOR PLUMBING. PER.MIT �ereby affirm that [ ha e a certiflcate of conseltt to self e ei (x eo) ure,or a„4,artif�aYe of Workers'Compens t on Ins a ce o � � ettifl cop her uf(Sec.3800,Lab C.) ..,^� �. u-�-^^�-�= -�•. ' `",. .� ' .. .�. . .. ��-��^�( Mllum -.Ssuc. � ~ pYy COUNT.YOFLO,$AMGELES BUI,LDfNG„ANDSAF�TY ulicyNo,. .,-. ComPanp . .,. . ,.... . . . � ��. . . ..-.. � .. . ....... ...._... .. ,:_,...,.� �, v.-r,.. �..:�:». � ... ^.r .m., a....m�an •v ,,:�-«�.A- . . . . �: ._ , ..... '' �.,w „�,..�.«..4,�._.,......-�.a.,..A.,..,..e...�a.i ,,.......�...�. ,. . . .,.. : ....:: . .'.. � Cer[ified copy is hereh:furnished. FOfi APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING • /� NUMBER �� FIXTUREORITEM • FEE �p'"p��s� 2Q�� �2`�17A� ;j��.r Dr � �ettified co y is filed with[iye¢ou y u�lding i spection _,__ . � ������� � � 9eP'.�1�r.Sva„{,�2 . L' � LOCALI7Y L1�.Tf1011(�. �n2' - ��==;r —�,, � p WATERCLOSET .-�.W.n m Date Applicant NEARESTp� � � ...,...,.,;�..,..�,.µ„„„. ._ BATH TUB .. . CR.Q$$$T , „&kR;�LrI„CATE OF EXEMPTiON FROM�W'ORKE ' �'��''` ��-'� � ' � r���"�"��� � �' � � � » F � CObiPENSATION(NSlIRANCE SHOWER OWNER T�1'. P'2CC;DE � � ..,... . . .. __.. ..�....,.»._ ..,,.... ...._ . (This section need not be completed if the woxk irtvolved LAVATORV qp AESS , S =me � � by the permit is foc one hundred dodazs ($100)or Eess.) SINK CITV �'1 �, B�+` '"" �_�yt O' � I cer[ify that in the performance of the work for which this � "���y��•��� . .�...��� .�_,. 7�-}=�� permit is issued,I shall�not em lo}•any�person in any manner DiSHWASHER ! CONTRACTOR �� � .. . .`rizomt:s i7rou o < P _ . . ._.......... so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ' qDDRESS ]_zi��� us �l,U u^',. U Uate Applicant ,,...'_._.... ... .._... . . : -.-..,».. ......,. „s.-.. . _ �. „..�._. .,,,,, .. ����- SWIMMING POO�RECEPTOR � � �� � NOTICF.`i'O�APYLICANT If,after making this CertiPicate of ".' � CITY ,;;�g_� �j G-r'O V 2 �vEL��7�^tO�i W Exemption, you.should become subject to the Workers' �AWNSPRINKLEFSYSTEM � � � Z� � Compensation provisions of the Labor Code,yon must forth- ', �� �� �-����� S7ATE � LIC. .... with comply �vi[h such provisions or this permit shall be � wATER HEATER � (�+O LICENSE NO. 2 CLAS�L�i deemed revoked. � �DISTRICT NO. PROCESSEO BY ...-_.....,�...„.,,._........,_._,.... ,.. G.4S�Sl'�TEMI OUTLETS / . LICEN5ED CONTRACTORS DECLARATION OUTLE7S OVER f Cj �„�,�y��� 1 hereby,a�f;t,r,m(ha[I,am]icenged under provisions of Chap[er SPER$YST€M. � � :.•� . . �9 commencin vith Section 7000 of Divislon 3 of the 8usi- � FINAL VALIDATION� � �` � 1 Solar pornestic ?ie<te.r ! ness and Professions Code,and my license is in full force and DATE _�_ , effect. _.GP�,... �_Z.. �.Y��.- � . , , � � ,3555�+ � 4� Bv^'-,� � : License Numbe 2 Lia CI sC' " - ,�q � � " ..............__. .. ... `�'�.�f,ti/.i�. � � . co�<<a�to...Thom:s �sro� 3/�j�2 „ � I a�'h exeinpt from the lic,ensing revuireme�ts as 1 am a Plan CheCk fee _ . � � . � � „_.luensed a[chitect or a registered professiuna] engineer � pLUMBING PERM�T ISSUING FEE$ �'�} - - � - ectmg in my�professional capacity (Section 7051, Bus- -�� �--�--� �-�- � . � � - �� , ' "� iness and Professions Code). " � � ' � � . � . � ' � TOTAL FEE ���� . Lic.or Reg.No. D•ute Plan check applicant - � - . , � ._ ... �1752A. �"'"��� �'� Name � ...HO'.b1E 0�1NER BUILDER DECLARATION .-..:- ......,._......� .....,... ,.,_._. � . �� ' � . � . . .... �:e • e o e� . I,.hereby 3.f�u'm that I.am exempt from the Contractor's Address ; . License [aw for the fotlowing reason (Section.7031.5. Rusi- Citq, Tel.No. 9,m e�� L,,S,Q ness and ProFessions Code): . ' ' � I,as_owner of the property,am exclusively wntracting� � � � . , @:� ° � c�_,Jr C�.. with licensed contractors to construct the project � � ' � $2 _ (Section 7044,Business and Yrofessions Code). . � . Q j,.O,�.- . ...............«.�,.......,-.,,..e�..._.:.... � . . . . , . . ,. . . . . .. CONSTRUCTION�LENUiNG AGENCY . � �' � � l,here6Y._�.fflr-k�E-�LdS���T.4.:�?.,£o,,qglr.yctip,F+lending,agenc3' .. . ' , . ,� ��. . _ . _ .. . . .... . . .... . .. � �.. fot the performance of[he work for wliich/]thu permit is � � � � - � �� � � issued(Sec.3091.O�v.C.). /) � . .. . . . ' � � � . . . � � . . � . �. Lender's Name (d„�,,,�,_ . . .. , . . . . . . . . . rr ru/L . ' ... .; .. . . Lender's Add�ess ,.,..,,�...: �...;.a...... .,._.:.... � � - i . . . . . - �- ,. . . . . , . I ce,rtify�that I have read this application and state that the � � � � . � �� � � � � � � � . � . above information is correct.I agree to comply with all County ^ -������-��� �����•� �- � � ' ' � -' -� � � � � .- . ordinances and State ]aws,regulating Ylumbing, and hereby � SEE REVk.RSE'rOR EXPLANATORY LANGUAGE �.� �� , ' -�' � - � . � . .' aut ze rep s ntxtives o�'this County.to enter upon the � � � � � � .�� � � , � , � abo e'mentio e property br inspection qurpo es. � � � � � � . . . : � ' ...'.. . . �`- ���� �] . . .. � , .. .. ., " , . .. � . . 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