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HomeMy WebLinkAbout1601A (9) ._— , �, '� WORKERS'i:OMPEN3AT10NDECLARAYION �c�s��w � I ,Aereby affirm �he� � �eve a��«E�,��ete of�a��t to se�f «.,,��-.o, APP,LICATION FOR PLJNiBING PERMIT ��sure,ot u certificatn of Wurkers'Compensation tnsurance,or ...-- . .. - � � - � � � �" cerNfi d copy thereoP(5ec.3800,Leb.CJ � ' - ' , � w��y-a9G 5%5 � COUNTY OF LOS ANGELES BUILOING AND SAFETY � Policy No. Company�,���'� . I � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN IPRINT OR TYPEI BUILDING��/� p.�.fl,n�, d��� ADDRESS � ����� �C' � Certified copy ic fled with the counfy buildi g inspection NUMBER FIXTURE OH YfEM • FEE , �-epar1 WATER CLOSET LOCALfTY�" � ➢ate ✓ � ADP��cant NEAREST / AA �,/ � BATH TUe CROSS ST. � ��G�G�/�ry ( CERYlF[CATE OF EXEMP'FION FROM WORKERS' COMPETiSAT10Pi INSllRANCE SHOWER OWNER /���yd`j/�'� LAVqTORY MA�� 6�,,��/� � (This section need not 6e completed if the wock invulved qooRESS 7G'J'G°7C� � 6y the pennit is foc one hundred Jollazs(SI00)or tess.) SINK } GITY� TEL.NO. O 1 1 ceKify that in Ihe performance of the work for which thi5 DISHWASHER U ' permit is i&sued,[ahall pot emplay any person in any manner CONTFACTOq so as to become su6ject to the Workers'Compensation Laws. CLOTHES WASHER �/���/,7 � AD�HESS �.T�.7 O Date Appiicant V— SWIMMING POOL RECEPSOR NOTICE 1'O APYLICANT:tf,after making this Certificate uf CITY � TEI.NO. W Ezemption, you shou{d bemme suhject ta the Workers' LAriNSPRINKLER5Y5TEM ��//' /� a. Compensation provislons of the Labor Code,you must forth- �ICENSE N0.`V'V � �L C ASSFI'� Z with comply with such provisions or this permit shall 6e WATER HEATER 9 � deemed revoked. � �� DISTRICT NO. PROCES3ED BV GAS SVSTEM OUTlETS �'7 LICENSED CONTRAC'CURS DECLARATION pU7�ETS OVER f`� 1 hereby afP¢m that 1 am licensed under provisions of Chapter 5 PER SVSTEM a"�'�`��� � � 9 (commencing with Sectiun 7000)ot Division 3 of the Busi- FINAL �, ness and Rofessinns Cade,and my[icense is in full force and � d��l 4ATE � �pZ �a VALIDATION � effect. /� r, 1 � fd'�/ FINAL License Numbr� I Lia Clasa gy ContraCto/Y�-Y� Date �+���4 � 1 am exempt from the licensing requiremen[s as i am a PIaR CheCk fgE � ticensed architect or a registered Drofessional engineer pLUMe1NG PERMIT ISSUING FEE$ � � acting in my proPessionel Capacity (Section 705t,6ur � iness and Professions Code). TOTAL FEE ,� � � Lic,or Reg.No. Date Plan c�eck applicant ! / /%f�• HOME OWNER-BUILDER DECLARATION Name � � I hereAy affum that 1 xm exempt Prom the Contractor's Atldress I,icense Law Far the toilowing reason(Sectiun 7031.5, Husi- City Tel.No. ness anJ Protessiors Code): � � 6 as ownet of the property,am exclusively contrae[ing with licensed rontractars to construct the projeet (Section 7044,Business and Professions Code). CONSTRUCI'ION LENDING AGENCY � 1 hereby affirm that the[e is a constcuction 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 � • • � .:,U� � � I certify that [have read this applicatiort and state that Ihe • c c � ?,Ct J� above information is correct.I agree to comply with ail County SEE REVERSE FOR EXPLANp'IORY LANGUACE ` ordinances and State laws mgulxting Plumbing, and hereby ��.� J�..�C authorize reprezentatives of this County to enter upon ihe above-me �oned prop�f�ty�fo�r in�sp.ection purposes. - ✓�lJ�'lr'L'� iri.ri�� • �+ �--- igna urc of Permiflee ate f i ! � � � .� �G�� �y��� � � �'� \ � � a ' � �=�dd :� � �, P d --� �� "`�., ~ � y�� � , uc; ^�" �. ;��•� a� r E.,3 ��o ? .,, � , 'n.n a ��.. �O � �' C « I s �'.� v � , ' ' � � � o'v=.�, o .: � �. i� .. o n• w+ a•-- {{ . f'✓`J,}O � �v' O ..U �'' �w.-,� ^�i'vO.. 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