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HomeMy WebLinkAbout0922A , I hereby,aifirm that I have a ATION DECWRATION ��� �� • � �� . �� � � � � ;. ' WORKERS'COMPENS � . . . '�' certi{icofe of consenl to self in-- ��6�PW 4i87 A � ' • . PPLICATION FOR PLUMBING PERMIT � 76A667A � . . . . � . . . .; �sure,or a Eertificale of Workers'Compensatian Insuranre,or a : � CE 817�REV.BiB6�.��" • " � ;�'.� � �� . : � .� �.��� �� � • . ' �� � �., ;�e;t`(ied copy Ihereof(Sec.3800.Lab.C.) ,.. . . . . ' . . •. . . . . . . . ... .. . .. , ... , .•�r..i�C �� ���/, �,.,,��?. �� Y� � CdUNTY OF LOS'ANGELES � DEPT.OF PUBLIC WORKS �.Policy No. '�Company _ ' , . . . . ,. � � • . . . . . . i�� � Ceriified�copy is hereby f�rnished. � ��� � � � � .�� �� � ,BUILDING � . , �RAPPIICANTTOFIIIM(PRINTORTYPE) . �1: . til�r•+I.':� C/In�:� � CertiFied copy is filed wiih ihe to�nty building inspr.ction� � ADDRESS.^ �/J S� ; �� �department: � . � � . ER R OR IT ����TM � ... . . ..... . . ... .. - .. . . . . ... NUMB �. ,'FIXTV E EM � �FEE ; l}!,•)!:l+�:;:i� . ,�.'�'.' :.-t � Dare. S'�f•'y � .. AppliCanl, ~J�/IC.�'.•�"%'•.' � WATERCYOSETI101LET� � � . . , . . . • . . .. NEAREST . . ...... ... . ... . .. . . . . . CROSS S . ... .' .: :.. . �' ��� - �� CERTIFICATE OF EXEM,PTION FROM WORKERS'.�. � �� � �� � �� � � ' � � �- ' '" � BATH NB •.•.... . ... .". :�.. . . . ..� • .. .., T. �•. � �"' � ' • 'COMPENSATION INSURANCE ' ' � � � . . OVJNER l i • •::[.:,:.c�..,,,, . -�-.--T.,�--�=.�' ' ;'�. � .... ... SHOWER�.:: ...:-., � �i l i'Y e!C -_ ... .• ...�.:. ... .. _.. _ .. • (Thl�Nction-n�id not 6��cortipl�tid if Ihi�work Involr�d by...� ... ... ' .. � •. NAR � . � . i. . 1hd p�rmil it For on�hundr�d dollan(SI00)or I�n.) . . . ' lAvaTORv , .' . . ' ADDRE55 , '= . ": . �. . � �I certi(y rhol in ihe performance of the work for�which�h�s per=��� � � . � . . ., . .. � . . . .. . _ '•�';- mit Is issued,I shall not employ ony person in ony monner ea� '' SiNK.; � � � � ' CITY . '' -•- :.. .� . . TEL.N0. . , � ,. '"� os�o betome subjetl ta the Workers'Compensotion Lows. . �.: . D�SHWASHER� � . �� . R (�„ / • �. � . . .r . _: .. . . . . . . ... . ' . ; . . .. .. ... . � .. .... .. . .. . ... � � CONTRACTO �4+///�. :l.II(!y':��..1._%.�:. .r,�+l. .. . ; .�'Datd.... �.. .� APPlicanl � � ' .. ��� . � �. ' CLOTHES WASHER . . - . .� .:. .',(!`, . � _ . . , , � .. .� ADDRESS ";:Jr�/�.:�'./. . � : ..� . . NOTICE TO APPUCANT:Jf,after moking this Cer�ificote of Ex-�, � SWIMMtNG POOL RECEPTOR '� � ' � . � " emption;you should become su6ject 10 the Workers'Compen•; � CiiY . ��+�;�f f�,;G•,� .- TEL.NO.�]�/,'��-,;;; . . � sation provisions of Ihe Lobor Code,you�must forthwith[omp- � / �q�,ry�.�SvRINKLER SYSTEM /.� ' ' ' '' `�I wah such rovisions or this permit sholl be deemed revok=��`' ' '�'� ' ' " �� ' STnTE � � �� �:.UC. . ' "' " . y p . .i ..� . �'..�ed:^' :�....:': :... . .. . _,.. . . :.'. ' � . WATER HEATER. . , .. . ... . .. ://'/(,' LICEhSE h0.�. '�/.. � QASS . �.✓ 7' . � • • � LICENSED CONTRACi0R5 DECLARATION'�; • � � DiSiaiCi NO. , . FaocEsseo er, , . � .� GAS SYSTEM� .'OUilETS . .. . . . ... ....�. . . . .. , . •,:, ��I hereby affirm�ho�I am I�cerised undar provisions of CI+aP�er . .. .' . . �.... :.• �. i/f ,.... _ . . . . .. ..�y•.,.,. 9(commencing wilh Seclion 7000)of Division 9 of�he Business OUILEiS OVER, ' ,��� . d';.�� ...... .. . . . .. ..� � . :. .... . ! ' ' and Vrofessions Code,and my license is in full force and ef-' � � 5 PER SvSiEm �� � FINAL �� � . � � VALIDATION•�� � . .V, � '�. . ., � . • . � . . �:....: i ,� . ... _ �� � . _ Fect.. . .L/y//'/�: .. .. . �.' . '. ... : DATE � , W•. '. . .. . ' . '. .'.: . . .. � � �.�.�.�,,License Numbe/ -` Lia Class L � ' �� �- ._ ,_.. � . , . . .., ��� � � �J '--':.::......_,"..�..__........ :_�.�.�;..t:,..:.:..y.�y:.r�. . NAl �.� ' ' �._ _ ..._ ,... - - - • . . ..., . • . . .. . : .. .�. '..� � FI ' � '. LL�. . ......---....._..._ ...•. ... .. ". ' / ... �..Contracror-i::%..�._.�frlr.. -'Dofe 1. 1(1��` . . � , � . . , BY' .. • . � ' '��' � . ... ... ....., ......._....._. ... ---,'} ' �.�,.�,� � I am e�empl under Sec:. .. �. . . .. . , .. . . - . , . : .. .�._ .. � .... . ... ..::.¢.,.,.. ❑ . . . . .,.� .. B.Sv.C.�o�il;�s reoson',. . . � Plan check fee . , �d . , ... .. , ... . . . . . .' �' .. . . . . . . '. . . � '. . .� Do�e: � � .PWMBING PERMIT ISSUING FEE S. �.: �./!/. y'�. . . . . � ... . . , . . � W....�� ... ' .��. �Signa�ure� . . . . .� , . . � . . . ` ^ . . . . � , ;..��.:...:-' . ... . , '. . . .... '..�.,... ..'. .'. ..."..'.. . ~(J: . . . . . .. . . . . . . ... _ TOTAL FEE . : ' : ., ` . ... : .... . . ...: � . : ... . ......... . _ ._..._.__._ ....._...._._._SINGLE FAMILY--^r-—^---�—_---��-.-_.. � -•---'----�-�-------..�-- ------ - ... ._.....---..._....- - ... � � � � HOME�OWNER-BUILDERDECLARATION���� '���� � ' P�o^�heekopplicant � �� �� • . � � �• + . - ' I hereby'offirm Iha�1 om eiempt irom the Contrac�oi s License ' � Ncme . ... . . ... . .. .. .. . . .. ... .... . . ..�.. ... .!�I-. A: ..�... . i„.:.. Law for Ihe(ollowing reason(Seclion 7031.5,Business and � � � � � �� � � � � �� � � ����7 L�It �� �• � ,�� �Professions Code:. ..... .... . .. _ . . . . Address :. ... . . . . . .. . . ...... . ... . . , .._ . . . . . �.��.�,�. . .. ... ) . . . . .. .. .. � ' . , .. , . � �. 4. . . . . . �.:�4:�i�'�i� ' � :�� I,ns owner bf the properiy,will do ihc work and th�e �� City. . " . . .�Tel.'No.. . . ,_ .. . . .. . . . � � „.,�.,:.:.,: .. .. � s+roctuie�e not�mended or offered for sale(Sed�on 7044,� � , . �,I�i�,!;,�,��.r]��t = � , . ,�;� � �; Business and Professions Code). . � . . . ... . . � . , � .. . ... ' . '. . . . ' _' . . �� !����� . :.. .. . . . . . . ' ' . . . . . . . . .. .. . . . .. . . . . . . .. .. ' �. . . . . ._. :. . � �. . . . ..� . .. '. ' . . . . . � . � . . � CONSTRUCTION LENDING AGENCY .•�� � � � � � - ' � . , . . .. . P� . � t,•,�i �1;� ... .I hereliy ollirm thal�here is a construclian lending agency 1or ...-;:..;� .;...-�..,.:.... '.�:.��:. . , -. -• .. . .. + - .. .. ' '. - . . .- .- ....P'�-!,'7„ .. ../.:;.. tha perTormance of the work ior which ihis permii is issued �� � � � ' ' � I.�� � '� " '—(Set.3097,Ci'v�C.�•',:-. . _ . _. . ... ...._ .. .. ..:±�::.:. . .' ._: . _�.� .. .._.:.......... . ... _.�.�..�... ....'.__. ....... _..: . .....:. ..:�:. ---------- ----- �. : . , . . . .. .. ,. .. . . , - . . . . ... . . . , . . .. ....... . . . . � � . .� .. �� . .. � , . , . .. . .. . . . . .. . lender's Name � . ' , . . . . -.. . . .' .. . . . . . � . . , �'Lender's Address . ... .' � �. ..'... .... ..... .. . '�. 1, .. �� ,... . . . . ... .' : : � � . . . . . .. . � . . . � ' .. � �I cerlify thot I hove reod this applicolidn and state ihol the • � � � ' � � • � � � � �� � , �� above infoimation is correcl.I ngree fo comply with all Covnry .I� � .' ' . � � ' � � � ' � �� � � . � � ,�� � ordinonces and State laws re ulatin Plum6in and hereb � . . � . � , � .,�� ' . � . .. . . . ' , ... . . � 9 9� 9. Y�.. � . •.� i�.� . , authori:e represenia�ives of this County to enler opon Ihe , '� � � . ��� . � � e . � � • � , . . � obove•meniioned properly ior inspection purposes. � , . . . . . . ; . . . . . . . . . . . : �` ';. ' � .. . . .. . . � ,y,Y SEE REVERSE FOR EXPLANATORY LANGUAGE. ' 'i • :%�li:. � /t`.-`%,i . '. • ' .' . . , .,' ' Signature of Permitlee ' . . � ,Da�e�.. _ . : . . • �; . � . � . . . � . � . . �. . � . .. .. . . . , . . • � � . . :i � .. . . , . . . ., � �• . . . �. — .. • t , . ! . ' � . �` . ' . `1 ' , . . . ' � . ' } . � ' .. � . � . '� . . �, . . . ., , , �1 , i � ' ' � � • .. . i , � , ' � �� , 7 , • � � 1 .. � • . ; . . . , ' ' , . . • . ' s .` • • . . _ , ;, _ � .. :, ' . . . �, , 1 , ' . . .. ' . . 1j ' � ' ', 1 .• , , , _ � � . � i � - , ' � . . • � ' . i • �