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HomeMy WebLinkAbout1141A (5) , WORKERS'COMPENSATiONDICLARATION � JBA669A � he«bY �tr��m �aa� � ��av� a�e«,r;�ate of consent to se�F �E.,�,�Z-eo, APPLICATION FOR PLU,.M,B ING PERM IT �r. '`�Iinsure,or a certificate of Wbrkers'Compensation Insurance,or . . n certified copy thereof(Sec.3800,Lab.rCf.r)�('`LL COUNTY OF LOS ANGE LES BUI LDtNG AND SAFETY .Policy N6(LL—w'QL�sCbmpany ��•�`YI 1 [i _ , . . � � Cet[ifieti copy is hereby furnished. FOft APPIICANT TO FILL IN(PFiINT OR TYPE) BUILDING �1 � Certified co UMBER FIXTURE OR ITEM � FEE ADDRESS O( IO I , � py is filed�vith the c unty building' spect�on . � ��—��Q(�t� WATER CLOSET LOCALI7V Uate��APPlicant NEAREST BATH TUB CROSS ST. �� CERT[FICATE Ok��:XEM1SPTSON RROM WORKER5' COMP1iNSATIUN INSURANCE SHOWER OWNER LAVATORY MAIL �� (This section need not be completed if[he woik imolved qoortess�, _ , �' by the permit is fur one hundred dotlars (5100)or lcss.) SINK Y � CITV qVpS�� C7 , I certify that in the performance of tha wurk fw which this -- U �. DISHWASHER CONTRACTOR�x permlt is issued,I shaU not employ any person in uny mannec _ �.i so na[o hecume subject to the Workers'Compensation Laws. C�OTHES WASHER ADDRESS �' '� Date App�icant SWIMMING POOL RECEPTOR � 'C� NOTICE TO APNLICANT:If,after making[his Cettificate of - CITY T • 8•� r a � Exemption, you shouid become sub�ect t� tbe W�rkers' LAWNSPRINKLERSVSTEM Compensation pravisione'of the Lubor Code,you must forth- STATE LIC. /7�/ /��j r� ivith comply with such prqvisions or ti�is 9ermii shall 6e WaTER HEATEF LICENSE N . O CLAS'u'�� QL+„] deemed rev�keJ. GAS SVSTEM OUTLETS OIS7RICT NO. PROGESSED BY `I.ICh:NSi;ll CUNTRACTORS U1:CLARATION OUTLETS OVER J�t-a ` .�-�,�+r . I hereby nffirm that f am licensed under provisions of Chapter S PER SYSTEM — � -- 9 (commencing wiih Section 7000)u£Division 3 of the Busi- ,? FINAL . ness and Professi�>ns Code,and my iice.nse is i��fWl force und �GQ. ��� �AT�� ��� VALIDATION effect. �1 License Numl>eY`��� Lic.Clase� ��+`�� FINAL � @ BY Contractor�J� Date���� � Plan check fee � I am exempt from the licensing requirements as I am a ]icensed architect or a registered professional engineer pLUMBING PERMIT ISSUING FEE$ '� � � acting in my professional cxpacity (Sectinn 7051, Bus- � . iness und Professions Code). TOTA4 PEE S� '�1 1 G,1 A � ; Lie.or Reg.No. Date _ Plan check app�ir,ant � � n m c ��° v HOMF.OAVNER-BUILDER DF.CI.ARA]'ION Name � — — — 1 ! G 7 Q - 1 hereby affirm [hat I am exemp[ f'rom the Contractor's Atldress — • � y y Licanse Law for the folluwin reason Section.7031.5,Rusi- � � Z' �� � S �• CitV Tel.No. ncss and Nrofessions Code): , �2�g�,�� „ �. � I,as owner uf the property,am ezclusively contracting . , with licensed conhactors to construc[ the project . (Sectiun 7044,Businees and Vrr>fexsions Code). CONSTRUC9'iUN ld!NDING AGLNCY 1 hereby afTirm thn[ there is a conctruc[ion lending agency � for the perfor�nance of the work for which [his Permit is - - ' issued(Sec.309'1,Civ.CJ. Lcnder's Name , Lender's Address I certiTy[hat I hnve mad this application and state that the above information is rnrrect.1 agre o comply with all Cowuy SI+.R REV ERSH'FOIi CXPLANATORY LANGUACE o dinunces and Statc laws regulaf Plumbing, and hereby �. a orize represenh bes of this nty to ter upnn the o c-mcntioned r �rty � � spe n ses. �a aa-g� nature of Pennittee D e �� � C'� y "� -�-_l� ➢'C.�'GI,�lN`NIO�n'�� �ZI � Z t�,`.� I��tS1�L��'��tZ4;.''7',v D fl Ta � �', �� '�'tiT'','0 �:n 1 7��.9 :, - '" m a1'�.�.,' r ,,� ,t�`,N �,y��'���I� iJ'', q� ��' �v ,,f `T•i=!`.:- i T 1�°, '�r `. ��t, X i� � . � .��; �.��,I `, t �y p', 1'�' �',1 �,z 1�?�i�.n x .. -�, -. ��, r.... �- ! g " . . �M� A� , ' T` �'' 1 i . �� �;n'• pD : �', �jl i�l�i' � l s-r- a^..� � t � � �,�- . .. � ` 1 ' �- �, ' �a' _..�. , � �'- . - : 11 � ` ' � g .... ` .�, .. . �f� `,SV y� ' ? ���_• �J 1� ^V� ,'�1 U'a � �I �l.�., �,..... 1 1 -:� V �k ., �` ...• y �.,*'�R � +� ,` y� � m� ' 1 . 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