HomeMy WebLinkAbout0882A µ'URKERS'COMPENSATION DECLAItAT10N �awavw �
I hereby aPfirm that I have a certificate of consent to 5e�t �e.,,,=-so, APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Wotkers'Compensation Insurance,or
a certifieQ ropy tfiereof(Sec.3800,Lab.CJ COUNTY OF LOS ANGELES BUiLDING AND SAFETY ���,
Policy No. Company � '�
I � Certified copy is hercby furnished. FOR APPLICANT TO FILL IN(PRINT DR TYPE) BUI�DING ���L�y�� O
� Certi£ed copy's filed with the county bui{ding inspection NUMBER FIXTURE Ofi ITEM • FEE AODRESS Y.S
depart`Aent. WqTER C.LOSET LOCALITY � �
Date Applicani NEAREST �
BATH TUB CROSS ST. ' �
CERTIFiCATE OF EXEMPTION FROM WORKERS'
COMPENSATION[NSURANCE SHOWER OWNER
LAVpTORY MAIL �
(This section need not he completed if ihe work involved aDORESS
by tlie pennit is toc one hundred dollars ($100)or leas.) SkNK }
cirv a O �
I certify thut in the performance of the work for which this ❑�gHWASHER V
permit is issued,[shall no[employ any person in any manne� CONTRACTOR �
so as to become subject to the Worke�s'Compensation Laws. CLOTHES WASMER � �
ADDRESS Q �
Date � Appiicant SWIMMING POOL RECEPTOR ~
NOTIL`F.TO APPL[CANT: If,afttr making this Certificate of CITY TEL.No. V �
Exemption, you should become subject to the Workers' LAWN SPRfIVKLER SYSTEM � STATE LIC. a s
Compeasatinn provisions of the Labor Code,you must forth- � �
with comp{y with such provisions or Ehis permit shal3 be
WATER HEATER LICENSE NO. CLASS � �
deemed revoked. GAS SYSTEM OUTLETS DISTRIC7 NO. O E SED
LICENSED CONTRACTORS DECLARAFION OUTLETS OVER Q Z �
I hereby affirm that I am iicensed under provisions of Chapter 5 PE R SYSTEM
9 (commencing with Section 7000)of Division 3 of[he Busi- FINAL j
ness and Professions Code,and my license is in full Porce and DATE VALIDATION �
effect.
a
FINAL ��"'i _ �
Littnse Number Lic.Class By (/'
Cuntractor Dxte . �,����� �
❑ i
[am exempt from the ticensing requirements as 1 am a Plan eheck fee �}
licensed architect Or a registered professional engineer pL11M81NG PERMIT ISSUING FEE S �` z �
acting in my professional capacity (Section TO51, Bus- '
i
inesa and Rofessiona Code). �� �-ze� � �,� p
TOTAL FEE 7.�
Lic.ur Reg.No. Date plan cheek applieant � '�%��:G.r i', �
_
HOME OWNER-BUILDER DECLARATION Nama � '..e e '� •a � j
Address p� � ;
I hereby aff'vm that [ am ezempt from the Coniractor's � q;�;� n �-�� �
License Law for the followin reason Saction 703L5, Busi- �1 ` '
ness and Professions Codn): g ( ��ty (< Tel.No. �� � _ � (�� �
�-y k
I,as owner of the property,am exclusively contracting /
� with licensed contractors to construct the project �/� � � , / _<,�'', =S?'� �
(Section 7044,Susiness and Professions Code). - �
CONSTRUCTION LENDING AGENCY -
l hereby affirm tha there is a onstruction lending agency
for the pertormance f the � k tor which [his permit is
issued(Sec.3097,Civ.C.
Lender's Name � ;
3
Lender's Address (
t
I certify that I have read this application end state thxt the �
above information is correct.[agree to comply with atl County SEE RF.VERSE FOR ERPLANATORY LANGUAGE �
or 'nxnces and State laws regula[ing Plumbing, and hereby
au[ r', epre � his County to en[er upon the �
ab e ne pr p rty for pection purposes.
7
— � �
' na ure of Pormiitne Date �
�
0
� ,
,
� � , ' .
c? ti
,,,, v,`" -; �1 �1
�.• � � u v'..rG'� � -� , ` � ,
tl c+a' �_ -.? �_=1 „. ".: 3"; p i 'u =�o �,` �t, �. :
= � o; . w
; `; » 1' " :i, p.i � E' " L.. . `
'� `n� _ c=+p c..� i o i� ' : � "' :� � o. W �; ,
'�^ ;s� c�'v:, h m _ � i w �• .. =c"�. � `l
M ,� � a �, y.
U C v M � ��.1 .+ S,`r'� 'r Y,'�C' �. ,c.+,� _ ' .
N�... � " � a o, � c �V r n`, c:� � - ,
� G. �O,Y.`.•Y� �'^� 'y n �y �q � �r j��,Zy S^ �`� ` � � .
(7 � <, � ea '� �i a. G z y c. ��� j u a . � �;^ �,. � � .
.� c� " o. c, �';i� .M�. . ^`;µ _ c. ��
� �~�,�, �s�, 'c c o=o ^ �j•� 'c'v� �V ' � ,: .
J �'' s L'"t�.- � =,c c�,cs_. i.•`U� x= _ � ,_"�, ;•.. �^r .
y O Or`t. o� ^. c o' -- "� g .. "'o; c.� - = i
.l�. c� o+ � �o'C � .. �9•, •t, �i.� :.�. .
% 'f " -�= � .`� ii� u� c._- , r:..Y_�* �i ^. � . _
. C.� ry. a ' � .� Q 'iz G % ` " :- ,r„ c� _ '� . .
r �.�.� •�4 4-..... ..G ��' n (:.. Y'
G .-. � V.✓ < • � y,•. i �
/�'� r'. c Ci O C : t' r. �C J': G .:. ' a.S 7°; o ci t... 5. '�{
�... � � N z� : L: -' _�e t.- •:•�. .:' :' ' ;�.: .:.' -,�_�: rv
yF` S �[�+�. v V N� �� �`"~. ='. `; r �� _ 'x�"-• �' �`,� r � 1 1
f, ,,,,'" G,^'w c i:.. = �«: u�G'G` �.•1:�." .,'....� � y:. ^ �' S�. � \ \ �•, ,\
� .� 4' r - ^�, �r; ,. a _» -.�.:a '' :�. •.,�_: .. � � G':
y , y o> "�v: s.,.
� ✓ s1 C C � o� '� ' _ �_ ��.✓•.. . . .� _'1�.L" G_.. \.
r+- T�-. _ �`""�^ '� C -. . cC. �y.., .. i�• \ �
M y,': c,(� ,., c O � c5 .'- w �� _. �.• �:4 c C,C" \ \
t'.'�. Lt � = i C ' t C C "' =G . ',.i ' i .. ` \
�L �^;, l cs cY v ' � ° v�- � V! '— c'` \ \
� v�' � ,�,j i •�Y " :- i a .L� .. ` .
•4 � C v j�~� �4G.� ���Y . �� " ` \ . 1 � \ `\} .
� '�,C!�.�3~� � � � ` ,r . \ � \\.
' 1 1 \ ` . , � � \ ` \ .
\ � \1 \ `
1 �+
` \
! \,j�`. . . �
\ ' . 1•� �'. } 1`.
\� ,\ 5\ , i; 4,\ \
�\ ! , �. .\ . �� .
� . ` .\, `,� •�\�. . 4�\�� `;` ,'1
N \ ' � `\ , \ ,�4t' ,,'� `� ` \ \` \
i . �� �t . t� '� � � 1
y ' `
o �� ��, � � `� ,� '� � ,'� \
Z � '` .\ � \ �` '�� � `
tI � 1 ` ��� \
O '� ! ` \ � 1 � `
r� \ `1\ � , ` `
Z � ��\ , � �. � �
� � �. , t
, � �
, � �
�
�` �,
\ � �� N
1 W
• ro
2
W� N
� O `
~� r�
N
o ��\ � .
V ... . ' �',� .� .
�� ��� � � �\ ��
� \ ,�
. Y 1� \'� _ �'a , ' �_
�T
i /�.
O � � � p1 � j �,�
W '� O
LL ,
��. .;�Fw, 6 \�; '�6d ...
. ,,._,--_.
`O�t o- ',_�--",:--
2 `y X`. ���, �'\�4
cnJ`� � ,¢ LL r p'` N F
ei m � �7 r ,w �,N ,y' '�'i
02
O t j 6 ? W Y�Q �`\Y`\��. Z; Z?i
ao.`� (�.`) �" N`1 Y �.`Q 't',, tl- ��i�'a w
. Q`p O Q �;�y�'�'�f��
`� ��� '�
,..-�"�'
/ �