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HomeMy WebLinkAbout5748A (17)WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or C certificate of Workers' Compensation Insurance, oda certified coy. thereoo(5, 83800, Lab. C.) Policy No. , OQ' Co/PamrilI f1r4]iiti— Y Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. Dote -7-1141 Applicant CERTIFICATE OF EXEMPTION M WORKERS' COMPENSATION IN ANCE This section need not be complete if the work involved bythepermitisforonehundreddoliars ($TOP) or less.) 1 certify that in the performance of the work for which this permit is issued, l shall not employ anyperson in any mannersoastobecomesubjecttotheWorkers' Compensation Law, Date Applicont NOTICE TO APPLICANT: If, after making this Certificate ofExemption, you should become subject to the Workers' Compensation provisions of she Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed -under provisionsof Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number _ 9.! tQfLic. Class _ Contractor _ —_ Date _/ I amFmrp' under Sec. B.&Pthis reason Signature SINGLE FAMILY HOME OWNER -BUILDER DECLARATION I herebyaffirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Cade): I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Cade). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency fortheperformanceoftheworkforwhichthispermitisissued Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all CountyordinancesandStatelawsregulatingPlumbing, and hereby authorize representatives of this County to enter upon the above-mentioned ,p,,,rrro jjo'''\ pperly for inspection purposes. Sign re of Permittee Dater 76A667A APPLICATION FOR PLUMBING PERMIT CE 817 {REV. 10/81) COUNTY OF LOS ANGELES Plan check fee PLUMBING PERMIT ISSUING FEE $ TOTAL FEE Plan check applicant Name Address City Tel. No. SEE REVERSE FOR EXPLANATORY LANGUAGE BUILDING AND SAFETY ADDRESS [7[/ -IU LOCALITY Dl}}h'1. NEAREST CROSS ST. OWNER -C LI fi MAIL ADDRESS CITY a PJ TA/O CONTRACTOR 60,6D ADDRESS tigg 0)c , CITY r STATE LICENSE NO. 1 lual DISTRICT NO. FINAL DATE E FINAL BY 3TEL. NOWOOD FOR APPLICANTTO FILL IN (PRINT ORTYPE) NUMBER FIXTURE OR ITEM @ WATER CLOSET BATH TUB 1 SHOWER LAVATORY SINK O DISHWASHER V CLOTHESWASHER GC O SWIMMING POOL RECEPTOR H4.1 LAWN SPRINKLER SYSTEM WATER HEATER t GASSYSTEM .% OUTLETS Plan check fee PLUMBING PERMIT ISSUING FEE $ TOTAL FEE Plan check applicant Name Address City Tel. No. SEE REVERSE FOR EXPLANATORY LANGUAGE BUILDING AND SAFETY ADDRESS [7[/ -IU LOCALITY Dl}}h'1. NEAREST CROSS ST. OWNER -C LI fi MAIL ADDRESS CITY a PJ TA/O CONTRACTOR 60,6D ADDRESS tigg 0)c , CITY r STATE LICENSE NO. 1 lual DISTRICT NO. FINAL DATE E FINAL BY 3TEL. NOWOOD L TEL. NO. 3. r UcCLASS C PROCESSED BY VAL1111ATION O V GC O H4.1 risz.. 8748A e s a s a 5 1e4FL50 6 F::25I_,V 0919-94 k t 0 k\j§ƒk 2 E4 0.$$.} « k0 a'0e®_- 0rrm [%`7g%f| }/$2$ƒ u.-0 Eos _ Q-m Ia) 00a0E. 0E2 3; EtE E Q,ECc, -00 |: > eee%eztpm$£§I7as - ao 2,wZ a`-0 a Ea 4eee'i-0 E\z0E®!I£»m| {Z0 ee«°{E- -" UEtL°In 3)2 -LS E ,2 00J e-m§-0 aa:E)n-"Ix &tee©f-$2) t\ 4c, r" —0. -})ƒ! a -- —0 'D o CL ° » I § 4) cx r/ a 0, rEL \ i & } --4,0 Ott0 t 2&aa-C C, a§;a;eco0, r:L, s2°I 22*,»_ , 2flEfkmj§2«245 G /<«2« tDo0tr R;a2e ƒ2»|5!§@ k k 0 k2 ca 3 j 2}k(\2§ k m e b w k @ A I k \ 0 2 k k 0 kE§ 2 ca 3 j 0 2 k