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HomeMy WebLinkAbout1724A � -. _ ....--- -- -— --— � �"��`NORKERS'COMPENSATIONDKLARATION qpp��CATION FOR PLUMBING PERMIT /-� I hereby,oi(irm tho�I hove a certificaie of conseM lo self 7gp8B7A "1 I � msure,or o certificatepf Workers'Compenzotion Insuronce, CE 817(FEV.BlBB) � ' � �� LJ or a ca�li ie topy fheroo!(Sea 3800,Lob.C.) � � " " � COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS P❑olity No. Company , Ceri�f�ed copy is hereby furnished. ❑ FOR APPLICANT TO FILI IN(PRIM OR TVDE) ����� '� " .1 � 1. 1 Ceriified copy is filed wifh�he coumy buitding inspec- ADDRE55 O � N•i{/A�V v � �iion depurtment. NUMBER FIXTURE OR�TEM � FEE . �� W hLUvT Dote Appli4ant WATERROSET • . CERTIFICATF OF EXEMPTION FROM WORKERS' BAtH TU8 �ROSS ST. �CA'JO COMPENSATION INSURANCE ��ER �R �� LR7 L ! G (Thi��Mlon ewd nof b�eompl�t�d tf thr work inrolr�d bp ��i ' . � fh�p�rmif 1�for en�A�ndnd dollan(SI00)or����.) iavaroav -- apor�u 3 � l� I cenify tFof in the pariormonce of the wo.k for which this mil is issued.I sholl nol em lo on �NK �0�2.�t4�z S �.�.q/ � i �' P Y Y Pe�n in any nwnner � CITVG. �O (O . so os io become subject�o the Workers'Compenwtion Lows. D�SHWASHER CON"`"�` AtiyisT+e ,e Date epP���a^� ROTHES WASHER NOTICE TO APPLICANT: If,�alter makirg Ihiz Ceriiflco�e o( '� ,3 ,�• ,j tl� �/�.Y�� E:empiion, you should become subjact lo the Wakers' SWW1MiNGPOOIRECEPTOR � Compenwrion provis�ons of the lobor Coda,you must fonh• C�T�w. C'O✓I�IJ'�. �� TE�'�' ( with Com I with such �H`N��µKLERSYS7EAA �37 P Y provisions or �his permi� sholl be SinIF l�C. � deemed revoked. � WATER HEATER LICENSE NO. �i s-4 GtA55 � UCENSEO CONTRAC70R5 OECLARATION- � DISTRICT NO. ESSEO 8Y 1 hereby affirm tFqt I om licensed uider proviaions of Chopler 9 GAS SVSTEM WttEiS � i (commenNnp wi�l+Section 7q00)of pivis�o�3 of�he Busi�ess pU7lET5 OVER ond Protessiom Code,and my liceme is in full(wce ond effx�. 5 oER SvSiEn� � FINAL VALIDATION O' License Number M� Lic.CI�� DATE t� V �7•{C 3� '�T FINAL A,� Comracro Doro BY � ❑ I am e.empt under Sec. y�, � B.BP.C.for Ihis reoson N6 Plan check fee ► x �� ttUMBING PERMIT ISSUING fEE S � x Siqnoture • t TOTAL FEE 5 .�� ��ll n Plan check epplicant ' ' �F SINGLE FAMIIY �' • • ' • � HOAAE OWNER-BUILDER DECLARATION Name � � I hereby offirm�haf I am e�emp�irom the ConheUor i liceroe ' - � ' '���7� Law for�he(ollowinq reawn(Seclion 7031,5,Business are! �dross . . . . . Pro}eesiona Code): Y Tel.No. � s��.j r•T - ❑ Cit � I,as owner of li�e pfoperty,will do the work ond ihe � (Ci J—[5 7 strucfu�e is not intended w offered for�ale(Section . , 7Q14,Butinns and Professions Code). . " CONS�RUCTION IENDING AGENCV - � � - - 1 hereby offirm thal rhere is a consnuUlon lending egency fw the performonce of Ihe wor4 for whith this permil is issuEd - � . (Set.3097,Civ.C.). . . Lender i Name � Lender':Addreu � I cer�ify that I hava read ih�s oppl�carion and:toie�ho��he _. � , . above infwmorioa ia carect.I ogree�o comply wi�h oll CouMy - � ord�nances and Siafe lawc requlating Plumbing,and hereby authorize repreaenio�ives of�hia Co�nly�o entx upon the � a ve•m nlio �pf ny � iMpecfion purposef. . . . -. 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