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HomeMy WebLinkAbout1601A ._— , �, '� WORKERS'i:OMPEN3A'LIONDECLARA'CION iGA6��A � I ,Aereby affirm ,he� � �eve a��«E�,��ete of�a��t to se�E «.,,��-.o, APP,LICATION FOR PLJNiBING PERMIT ��sure,or u certificatn of Wurkers'Compensation tnsurance,or . ...- . .. - � � - - � � �" cerNfi d copy thereoP(Sec.3800,Leb.CJ � ' ' , � w��y-a9G 5%5 ./ � COUNTY OF LOS ANGELES BUILOING AND SAFETY � Policy No. Company�,�r��_�'� . I � Certified copy is hereby fumished. FOR APPLIGANT TO FILL IN IPRINT OR TYPEI BUILDING�//� p.�.ff,n�, ���� `,.,,C ADDRESS ��� J�`�� /`�`�I Certified copy ic fled with the cnunty buildi g inspection NUMBER FIXTURE OH YfEM • FEE , / �-eQa�� WATER CLOSET LOCALfTY�" � ➢ate ✓ � ADP��cant NEAREST / AA�p�,/ BATH T116 CROSS ST. � ��G�!�/!!��✓ ! CERYlF[CATE OF EXEMP'FION FROM WORKEkS' COMPENSATIOPi INSllRANC6 SHOWER OWNER /���yd`(/�'1� LAVATORY MAIL 6�,,��/� I (This secdon need not be completed if the wock{6VU�YEJ qooRESS 7G'J'G°7C? � 6y the pennit is foc one hundred Jollazs(SI00)or tess.) SINK } GITY� TEL.NO. O 1 1 certify that in the performance of the work for which this DISHwASHER U ' permit is i&sued,[ahall�ot emplay any person in any manner CONTHACTOq so as to become su6ject to the Workers'ComDensation Laws. CLOTHES WASHER ����/,7 ' � AD�HESS O Date Appiicant T�� V— SWIMMING POOL RECEPTOR NOTICE 1'O APYLICANT:tf,after making this Certificate uf dTY � 7E1.NO. W Ezemption, you shou{J become suhject ta the Workers' LAriNSPRINICLER5Y5TEM ��//'� /� 6. Compensation provislons of the Labor Code,you must forth- �ICENSE N0.`V'V ' �L CIASSFI'' Z with comply with such provisions or this permit shall 6e WA7ER HEATER 9 � deemed revoked. GAS SVSFEM OUTIETS ` �/� DISTRICT NO. PROCES3ED BY LICENSED CONTRACTURS DECLARATION L� �'7 OUTIETS OVER f`� R����/ 1 hereby afP¢m that 1 am licensed under provisions of Chapter 5 PER SVSTEM � � 9 (commencing with Sectiun 7000)ot Division 3 of the Busi- FINAL ' aess an�1 i'roCessinns Code,and my[icense is in futl Torce and c� d��� QATE � /pZ �a VALIDATION ( effect. � � r, � � '�/ PINAL License Numbr� Lia Clasa . gY ContraCto/Y�-Y� Date �I���D � 1 am exempt from the licensing requirements as 1 am a Plart check fee � licensed architcct or a rtgistered professional engineer pLUMe1NG PERMIT ISSUING FEE$ � � acting in my proCessionel eapacity (Section 705t,6ur � iness and Profe6sions Code). TOTAL FEE ,� � � Lic,or Reg.No. Date Plan c�eck applicant ! / /%f�• HOME OWNER-BUILDER AECLARATION Name � � I hereAy affam that 1 xm exempt Prom the Contractor's Address I,icense Law For the toilowing reason(S2ctiun 7031.5, Busi- City Tal.No. ness and Protessions Code): � � t,as ownet of the property,am exclusively contracting with licensed rorttrac[ors to conslruct the projeet (Section 7D44,Business and Professions Code). CONSTRUCI'ION LENDING AGENCY � 1 hereby affirm that tbere is a construction lending agency t �� �Q.� ht for the performance of the work for which this permit is � issued(Sec.3097,Civ.C-)./1/�- ' Lender's Name �-���� f'� � � � �" � Lender's Address � • • � .:,�� � � I certify that [have read this application and state that Ihe • c c� ?,Ct J� above information is correc[.I agree to cort�ply with aIl County SEE REVERSE FOR EXPLANpTORY LANGUACE ordinances and Stata laws mgulxting Plumbing, and hereby (�� � j�..�C authorize representatives of this County to enter upon ihe above-me �oned prop ty for inspection purposes. - �,L'C�O�� ;..-i.r��� • �+ �--- igna urc of Permiflee ate f i � \ ! w. --s�'_� � , �� j\ r � ,p ��� �;�T•y�~`w, . ,1 `1 .. a � V ci �, e� a> `�N e� 1 o� ��= >' ^ ".�. 3 � � 3 == L � i 3 �. o � � ` ej ��'� "" G 4.--.k =o' �„" � � s'C�.. � V � , ., . N v'1� ? �""' G.D ^J b � � N .. O �O� �' ��r e ' 'O M 0 c. ,�„�' S M �G.;,p ✓ �? 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