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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: t;E�-s �, _.Sfi "��Pw���` s W4 `^� 4 S 7 . . _ ' n�,,,�'.� , '� ' �,�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 • ° � 7 � `..T . �C, � �_ '� • . , ' . . •.�� Nc A ji����� �'N � o � � j '* �� nI�+Z�D y�Z v �'D � � �> �D� ° I-''_���A c� � � � I A I I ' I'\ O � I O' I� y I I� � O .) 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