HomeMy WebLinkAbout1290A (4) � a i'r�..' *F -�:��.,�.w �,..:;7 ^t ,::#:, -:,, ,k n :z�� � t � Av :�-'�';'��'��`�. j's�wrra.H;;, t �"'Z.!��` e .s�; a r-"�fid re.rSh ',.�."_ rrt ,'. 1 �C•aa.3�s=L'Sr' -�i:
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�,�WORIQERS^COMPENSAPI�OI��DEC6ARAT10 .•.�+ � ����� ��� � '��' f s_ ,/ }� `�r��, � I;
� �� � AP:P���A�T��}I�`���` PL�'JMB�IVG��RIIhIT, .�� �'� �
�'.�(�herebq'raffirm that I have a certif�cote of'consent�to�selR �yq�y7q y � � ; . � • a y,, i~
�n s re;or a ceriifico�e of Workers'Compenso�ion Insurante, n��CE.�17��REV�10�.{8}j+V t : , � . � �; i�2�p, 1 �� �." �`
or a ce�ti`�d�op�5��ec.3800�Lob.C.) ° �� � � ,�� COUNTY�OP LOS ANGELES BUILDING AND SAFETY _ �''•", m "� ' ;�b,',,m,
�i��Policy-Now�1 nipanY�i.r'"i.�L�i,t'..S �# ,i � . t, �,
-,Q , :r�4 � : ,.s;«°ax� . . � � ��. ' �.��.. u','��re
Certified copy is hereby f�mished. . k(
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUIIDING � y»� { �i � n
� ADDRE55 �Ly = �I�['.1 \? L`1
'1!� Cerlified copy is filed with the munty building insper � s'
tlo d parimeni. M NUMBER FlXTUREORITEM n PEE �OULITY t ��
,p�;Date � 1 Appl�cant `���]) ��\�'�+�'��� j WATERCLOSET Pv "` NEAREST � � �
� CE TI-�F EXEMPTION fROM WORKERS' � BATH T118 f� �j} CROSS ST. _�� ,,�.
5': I .
COMPENSATION INSURANCE SHOWER OWNER .� , yy*� �� �` �
�?(This section need noT be completed ii 4he work involved 6y �
-the ermit is For one h�ndred dollan 5100 or less. MA�� , �`;�!
p � ) ) 4�L.. LAVAiORY ,Z � ADDRE55 �� �i� i, a ,
r, ;I ce�t'fy that in the perfarmance of the work for wh ch ih s SINK CITY TEL NO. fi St
,�,perm�t�s issued,!shall not employ any persor.m any manner � �m,. ' ' S e.� "�1���'� + �;
�'so as to become subject to ihe Wnrkers'Compensation Lows. _ �',���`a#i
DISHWASHER � (',!� CONTRACTOR r"
�
;�Da1e _Applicant CI.OTHFS WASHER �'v V� qDDRESS� 'l . �� �'q�
-NnTICE TO APPLICANT: If, ofter making this Certifiicate of �� ?��;
�' � hon, ou should become sub'ed fo fhe Workers' SWIMMING POOI RECEFTOR y
'P Y i CITY 7EL. O. �'�j G'
�,�:�.. npensatio prov sions of the La6or Coda,you must forth- iawN SvkiNKiER 5v5iFn4 ����� �" ' �1 5� � ;����:
Ew�fh comply w th such provisions or this permit shall 6e STAIE �♦, ,• UG ^� y . ,�,,
-�af:deemed rzvoked. WATF.RHF.ATER LICENSE NO`"�. � CLASS ', � 4�.
$k" LICENSED CONTRACTORS DECLARATION � DI57RICT NO. • PROCESSED 6Y `^^} ��� '�
�:
GASSYSTEM OUTtFTS � 0 0 �'�'�`�
,q'��' �1 hereby affirm ihaf I am licensed under provisions of Chapter 9 � d� z "'�^�7
x�(commencing with$ection 70D0)of Divisian 3 of ihe Business OU?tET50VER . j� 'yi+�'�`�;
� y,and Profassians Code,and my iicense is in full force and ef{ec�. 5 PER SYSTEM FINAL / f�
�� . ,-,�,�t� ->� onrE� 3e � YALIDATION 1tir '�
!��License Number �Lic Class �� �� � S' � �'
y. � s FINAL / �}
�e _�'.? �t� �� 6Y /�,,�-,e�,� �,���%
�. Contracto�������'-�� �te � „��"""" .
.nar'�
�t❑ I am exempt vnder Sec .•.�'.
�'��" B.&P.C.tor lhis ieasan ' � d.t'�
,4�,s Plan check fee � � ;-��,
� y.�; _ Date: t PIUMBING PERMIT ISSUING FEE$ �`J �� a•'� � �
iz�� Signature ' Y'��. � �Ly
n���.:» S TOTAL FEE �(r7J .� `� :S U 5��. 's�:t',�.
�
�� Plan check app�imnt ° �' �
a"�� SINGIE FAMILY y � � -
i��:t'��`sM HOME OWNER-BUILDER DECLARAIIUN 4 Name � � � ���•"t� ����;
�"f.' �eby af4irm th�t i am ezempt from the CaNractor's License ' r. � 9x � ��
' Address
�!�, 'for Ihe following reasan(Section 7031.5, 8usiness and ( � ;' '
�i*���`Professions Code): ; City Tel.No. .� I r ., "����; y
❑ I,as owner of the properly,wiil do ihe work and the '�3,'s-: 4
,°��� siroctore is not iNended or offared for sole(Section � �" ;� "..�
A� 7044,B�siness and Professions CoJe). ';�
�'�?� CONSTRUCTION LENDWG AGENCY �
� ,, d
�'t�`�I hereby affirm thpf Ihere is n ronsiruction lending agency for , i
.„ b�the performance of the work far which this permit is issued �'° �'
,7,.,�?�(Sec.3097,Civ.C). �
,�'g� �y��<
f5�,�Lender's Name �; �� �;
f �� 5
�'�Lender's Address �����
y'""��I certify ihaf�have read ihis application and slale ihat lhe , ���
� -above informat on is correct.1 ogree to mmply wi�h all County �
"�f3�'..�ordinances and Stale lows regulating Plumbing,and hereby -
.=;"r,�i o�thorize represeniniives of this Caunty to enter upon ihe . . �
� ab�v c�meNioned pr pe ty far inspeclion purposes. �:_
�r", '{ � SEE REVERSE FOR EXPLANATORY�ANGUAGE
t`�.�, ����� "F7 J1r �,�a _'?.5h''' I
-6��ft-1/l.Tt ,7 �'/ ' --F� _.. , �y I,
.� Signature of Permiltee / �e • ° �
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