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HomeMy WebLinkAbout1289A (4) . � :-�'�':.� �.^:�,f ' .'..�� f '. . Sy, 'i'y.:.. �.��, .,. $h k . � f�i.:.,�'4 Y�,'...N4 .'.t;: -,y. � ?VJORKERS��COMPENSATION DECCARATION��'� •''fu 'f b���:` � 7�'+t�� � �� � � � r AP'FLF�AT��D1�����;PE�M��G PERMIT ; t �l hereby�affirm that I have a certif<ate of consent io self �6q«,�q .. .. .. . . y+ -s y `�insure,or a certificafe of Workers'Compensation Insqrance, CE 817(REV �0�81�o-. � a >r , � - 2 i„ ° .� �prvr-+ or a cerhRed mpy thereof(�c 3800,Lab.C.) ,...COUNTY OF LOS ANGELES BUILDINGlyIND SAFETY ? Y �"`'�`+'�° ;r . 4; }� t � a� �4�`�.��"�'� � ,y � \ � }�.,,P�oliryNo. la ompony 'iG,Y��fh�.�'S.7 `�Y "� y 1 .. ;� . t,. Certified copy is hereby fum shed. v ' ��� � �a � /,,❑ `�t FORAPPLICANTTOFILLIN�PRINTORTYPE) BUIIDING + �•J a,{ ',l /�rs w T..��;�` Ceriified copy s flled wilh the munty boilding mspeo . L_ ADDRE55 �T�,�L- � y����,�j�W iJ1 . ho de ariment �l NUMBER FIX7lIRE OR ITEM C FEE � ���i P�,�' (� LOCALITY �� �,x ti y� `�s � �.7 �\S �V�YYu��\C.�fF' WATERCLOSET � L� � .. �"�' .•�Date Applimni �s� NEAkEST CER IFlCATE OF EXEMPTION FROM WORKERS' vY BATH TUB f� "� CROSS ST. °;��,� COMPENSATION INSURANCE '� SHOWER OWNER ,� �� �� - � � ��C � �<t.{ � � ��.`(This section need noT be complefed if the work involved 6y i — MAIL � '�'�,� -the permit is for one hundred dollars(S10tl)or less.) ', LAVAiORv � ADDRESS �r ' t S: �w. KQ �'� � :�I ceriify that in the performance of the work far which ihis �`�r ��� SINK �t (� CITY T L NO. ,. �� -..�a,,,y� ,:permit is issued,I sh�ll no!employ any person in any manneY � 5ya �,,�C � C �J ��� ��?so as to become subjeci to the Workers'Compensatian Laws' ,.} �� h"�`y �'�d�e� UISHWASHER vv CONTRACTO � . � — y+ 1'�G r `�'Daie Applicant CLO7HES WASHER r � AODRC55�.y�y �^ �-5, `� F �r�� � d 'i�, 4., �,0.�\�) � � �, � :'P�nTICE TO APPLICANT: If, afler mak ng thls-Certifimte of M1.' :� m tion, oo should become subect to the Workers SWIMMMGPOOLRECEPTOR (� P Y I CI7Y ; 1 TEL NO. 'j�_ 1,�� �: . .npensation provis ons of ihe Lobor Code,you must farth- LAWN SPRINKtER SYS7FPA �+r��C e' �� ' ��� ,with comply w Ih such provisiors or ihis permit shall be � STATE � L�, LIC. r �:deemed fevokrd WA�ER HiAiER ��y LICENSE NO. � � 1 CLA55 �'..��i � ' ` LICENSED CONTRACTORS DECLARATION —�� -- --- oi5ieicr NO. r7 PeOCE55eo sr �' � ;.I hei'eby offirm thof I am licensed under provisians of Cfiopter 9 GAS SYSTEM OUTLETS � r�' �,+�, ,^ : i � ;�' ;(commencing with Section 7000)of Drvisior,3 of ihe B�siness i OUTtFT50VER � . �:ond Profossions Code,and my license is in full forw and effeU e 5 PER SYSTFM FlNAL / / ��Y ( /, / ,� ALIDATiON ' � � � i�� [ 7� ,�-�1s._ �ATE I�/'7!f�'S i �y.' 'License Num6er Lic.Class > � k�p.' � C��< C_ — FINAL ,.� ; .�.Contracto�"�V �s�\i.'h�.�l�[�te � •, ` �~ BY �'�'`'�''�'� �!"' 'n' �, '.� ': y ;.❑ I am exempt under Sec , � � �� � B.&P.c.for rh�s�easo�,— $ plan check fee � ���,4' `i, � 3 � ��te� PLUMBING PERMIT ISSUING PEE 5 r(f S �. �"' Signature ` +-'� TOTAL FEE (J� ,jro . . i;Y'�- *�,z,%��� �; Ty`�'• �?' Plan Check applimnt � u . � � "F:c� -'§- �' SMGLE FAMILY 3 — � �� '�`+l'�'�:5" HC7MEOWN€R-BUILCER DECLARA?ION q' Name , , . �`f�� " aeby affirm that I am exempt from�he Contraciors�icense � ' . }t'",��:�; 'for fhe following reason(Sedion 7031.5,Bosiness and "� Address _ . ; u �.�-_�, � Frofessions Code): : Clty Tel.No. �.'-� ��� I,as owner of the property,will do ihe work and Ihe �� � �` � Y � ti`cS�� siructure Is not niended or offered for sale(Section . , �e"1;�.� #�� ,p,,,;y 7044,Bos�ness and Professions Code). � (�t`,�+y� ��-'p'� CONSTRUCTION LENDING AGENCY �,F °k;' ��°�I hereby affirm Ihat ihere is a mnsiruction lending agency for {;, a.i�.-�a�the performance of the work for which this permit is issued ��,: .,�,�vi,`�(Sec 3097,Giv.C.). :� �µ r£ ts �� r �;�Lender's Name ���:�. �� qe "F '� '�`!Lender's Address � ',�""��'� � � ,'�I certify that I hove read this application and sto�e 1ha7 ihe � � �.;above intormation is corred.I oyree ro comply with oll CouNy '� � �`�� •:5 ordinances and Stote laws regulating Plum6ing,and here6y ��.',. n� , � �outhorize representntives of this County to enter upon the ., ��,�, � �ab e-mentioned pr perty for inspeUion purposes. t : �i�� � � SEE REVERSE FOR EXPLANATORY IANGUAGE � , � �E.; � . .. ���' ir' c. � v � nature of Permittee ❑�e ," ��' . ,. ._ F!3r.: L'r��tl Z C G+��O 10 q ���0` � . � �'� ' `n ', ��i� '/1 'C "s`;S' tn'D j Z iT 'O "O 'p � .. 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