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HomeMy WebLinkAbout1015A -: . ;;.q ;,;z ; ts ,. :::. :: <: °,`.: ; ,;,,;5 � �t':; � WORKER3 COMPENSATIONfDECLARA7,GON ,:. � - �: qpp���CAT�ON���FOR���P�LUMBINGwP�RMIT ��� � 1-�hereby affirm ihat I have a cernficate of mnsenh to selfL°� �bq��q:,,� 4 �.,c, • �j.� QOUI2� .�A� T11COE`�'1 ��` 'insure,or r�,cert f'cdte of Workers'Compensation Insurance v�F�..,CE ei7(REV t0/8�) . �; . y �, � � � � '+� �or cy ceFti9iedcopy�hereof(Sec.3800,Lob.C.) .��rr;' � ��= COUNTY�OF LOS�;ANGEIES BUILDING APID,SAFETY � �t�µs } ,. •"?r WC Selecb Ias � . . 3� �.�P❑olicy No__'����ompany . � q � .,� , ,� ; Cerhfie m areby furnished ��s'� ��"�'`�''�' ' � ;� FOR APPLICANT TO FlLt IN(PRINT OR TYPE) BUILDING 641 Stron bow `'O Cerhfied wpy is filed wdh Ihe coun uildmg inspec -��`- ADDRE55 � fion depariment. (}QQ BZ' $ ��b$• �G '� NUMBER FIXTURE OR ITEM �r FEE , 6-22-$5 �:. �ocnurv Diamond $ar �.Dqte Appliconl .� WATERCIOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' �� �`'� BATH TUB ceoss sr. Sunset & Strongbow COMPENSATION INSURANCE 'G' SHOWER OWNER K�� Raval � ,,(This section naed�ot be wmplefed if fhe work involved by � < MA�� ,'the permiT is for one hundred dollars(S�00)or less.) LAVAiORY ADDRESS 641 S�ro bOW ��d certif.y ihni.in ihe performonce of ihe work for which this ' i;permit is issued,I shali not employ any porson in any manner " SINK dTV TEL NO. C� t �jso as to become subject to the Workers'Compensa�ion Laws. �" Ond �Sx '�Jg �g�73 �� � : � DISHWASHEH CONTRACTOR �� � ; Geo Brazi,l Flbg. & Htg. ?�Date Applicqni CLOTHES WASHER ADDRE55 �.;NOTICE TO APPLICANT: If, after making this Certifiwte of � � ].'�f�4�O SO �2'09.C�W3,'y ;�;�Exemption, yoo should become su6ject to the Workers' � d, SWIMMINGPOOLRECEPTOR 1�p �� f-�Com ensation ovisions of ihe Labor Code, ou must forth- ��T� (73T(�lSSE� ���G`fc.7 TEL.N��..S2 � AwithP[omply w�ih such provisions or this ermif Shdll 6e . � �AWN�PR�NKiFRSv�TFM �� , , a sTnTe 4�4167� `�� C 3b ' ���.deemed revoked. ����; 1 WA7ER HEATER{,',}lAT1�E OU �ICENSE NO. CLA55 LICENSE�CONTRACiORS DECLARATION �'� DISTRICT NO. PROCESSEO BY � 3 �} - - ' 'r� GAS SYSTEM OUTLETS ;� � �,:.I hereby affirm ihai I am licensed under provisions of Chapter 9 � � �Q �, � j '(commencing wifh$eciion 7000)of Division 3 of the Business �b'. OUTLET50VER �'�and Professions Code,and my hcense is in full force and e�fect. ` 5 PER SYSTEM " , '�°`°�' FiNAi V IDATION � �t DATE " ` ��' .w.License Number� ��678 lic.Class C' 3� � 6!'": AC � ��Contractor Piumbin� Date��2����✓ * g'r A�i' S �.� �-�..;` � T'�+❑ i om exempt under Sec. ��a � !<. � �,?: B.&P.C.for this reason � — �; Plan check fee � ' Dofe: �'z �" PIUMBING PERMIT ISSUING FEE$ ].O 5� � Signafure Pr: , �C 5� . r� � TOTAL FEE �� � ', Plon chack applicart � ��y� a , SINGLE FAMILY .� �p P":�� ?. ' HOME OWNER BUILDER 9ECLARATION �� Name � '. "�"I hereby affvm ihat I om ezempt from the CoMractor's L�cense � ' +i � �i..,.,p�,u,e t�n�.._..y. ___ Address � � .,Professions Code): �V� "V"'Vy'J� V�� ���V�u j .. . G t'�, .�:; ;":❑ „ ,._.. : _ ,._�no,� o. . " '_� :V Ciry Tel.No. ,.. � ' I,as ownar of the property, 'll do fhe work and the � � °.I,j ��' structure is not Intended or offered for sale (Section ► f r c;,:: 7044;Business and Professions Cade). 0� CONSTRUCTION LENDING AGENCY i I he�eby affirm that�here is a construcfion lending agency for � ' .�;��'the performance of ihe wark for which this permit is issued ' � . ;:%.(Sac.3097,Civ.C.). � ,�: ,�,Lender's Name '��ir'�Lender's Address ;`�I certify Iha�I have read Ihis applimtion ond stote ihot ihe ► ,� "�above mformation is mrrecf.i agree to mmply with all Counfy � :���ordinonces and State laws regulating Plumbing,and here6y , , ',authorize represeNaiives of this CouNy to enfer upon ihe � 5 ,'����abov -mentioned properiy for inspection purposes. � � ' j3�k�'� � �� ry�j SEE REVERSE FOR EXPLANATORY LANGUAGE . I�k1�. L� P "Z Z'r i� j � Signoture of Permiftee Da�e It�.�. :% I��iJM`:: .. ... . ....- - �ei C it "' G� G� � �!—Ip�D D ��Z _ . . . . 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