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HomeMy WebLinkAbout1373A � WORKP:ILS'COA4PENSATIONDECLARAT[ON JBA66]A APPLICATION�FOR� PLUMBING PERMIT .� . I;hereby affirm thut I Iie��e a'certificate of consent to scif ee en(z-eo) , insure,or a Lertificate ot\Vorkers'Compensation Insurance,or �certifieU copy tltereof(Sec.3800,La6:C. � � � W U a�,1�,-� c`�� � GOUNTY OF LOS ANGELES BUI LDfNG QND SAFETY PolicY No. CumpnnY "'�v'-�-- . . � Certified copy Is hereAy furnished. FOR APP�ICANT TO FILL IN(PRINT OR TVPE) BUI��IN�Iq`r J/q) �� � �� ADDRESS �1 ls/!�_ . � Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE ��`-"- , � � 1• urt if. ' LOCALITY /� . � . t� .. Dute;�'��App�icant WA7ER CLOScT NEAREST �/\ . BATHTU9 CROSSST. �) �„Q'�1� (;} \��J�S�SC�f"� � CERi'IFICATEOf EXEbiPT10N I�ROM WORKF,RS' -- {�^ � SHOWER OWNER 1 �(,L j,',�� CO�]YlNSA'1'ION INSURANCE ��..�C�,.LI' LAV�TORV MAIL } � (This section necd not be compieted if the work involved � __ ,_ AODRESS ��_ ��1/� S��'2 �• �- by the pexmit is foc onc hundred dollarx (510�)or lessJ �� � � SINK-'__'-_'— CITY ��t O�._.���TEL.NO.(" � �'� U 1 certify xhat in the erformunce of the work fnr which this LT� �}- � � � V �ISHWASHER CONTRACTOR permit is issued,I shall nut employ any person in any munner ____..__.._ .5"��t���s,'�71�__.�i"'"N��•-�� •�., so us to become subject to the Workers'Compennation Laws. CLOTHES WASHER � Dute A licant ADDRESS ? _O�� i:�� t W PP SW�MMING POOL RECEPTOR �� NOTICF;TO APPLCCANT:If,aFter making this Certificatc of -- CITY - . �j',c� TEL.NO���'�]�9 e7 lxemption, y�u shqultl be�ome sul�ject to the Workers' LAWNSPRINKLERSYSTEM STATE LIC. � ' �j�) � Cnmpensafion pCOVisions Uf the Lub�r Code,you mu.�t foi[Il- � LICENSE NO. L. � CLASS���y7T� � with comply with such pruvisions or this pcemit shali be � `�1ATER HEATER i Je�med rtvokeS. DISTRiCT NO. PFOCESSED BY GASSYSTEM OUTLETS '(� LIC7SNSF.D CONTRACTORS DECI.ALLATYON ` OUTIETS OVER � � O•\�-����..,�_ - I hereUy aFfirm thul I um licensed uncler provicions of Chapter 5 PER SYSTEM , — 9 (commencinK with Section 70f10)of Division 3 of the Husi- q f � � PINAL ������ ����p����N ness and Professions Code,and my license is in full force and '�d.G� . ���'��0�•'�� ' �� DATE � cffect. � J �/ FINAL l.icense Number.�y �l Li�.Class I�"����-P - _ BY k Contrnctor�_ Date__� ` �, c�_ _ _ � [am exP.mpt from the licensing reyuirements as i��m a �: P�an check tee ___ Gcensed architect or a registered pmfescional engineer PLUMBING PERMIT ISSUING FEE$ ���•';`,f� . acting in my prUfessional cupacity(Scction 7051, Hus- . iness and Prufessions Code). TOTAL FEE /� Ei�`7 ' I.ic.or 2eg.No.___ Date ;Pian check applicanY I30\fE OW:�:IR-BUII,DP.R DF:CLARAT[ON , Name __ I hereby affirm that [ am exempt from [he Contractor's ' �""�`e5 — — �� ?,�7�;z�� Licensc Law for thc foliowing reeson(Section 7031 S,Busi- � City 7e1.No. a v • e e v �` ne�ss imd Professions Code): � � [,as owner of the property,nm exctusively con[wcting I ° �1 2.5 Q .. with licensed contrac�nrs tn convtruct the projec[ � (Section 7044,Uusinees and Yrut'essions Code). . ° � �+� C.�J�c�.� � i CONS9'RUC770N LENDING AGF?NCY . O f,c�B-S 2 I herebv afyirm tha[ there is a construction lending agency � u foc [he performs�nce of the work for which this permif is -- - issued(Sec.3097,Civ.C.). Lender's Namr,_ � i Lender's Address � I eertify that I have re=id this applicalion and state th:it the :. � � S. abuve ioformatiun is correct.1 ag�ee to complY witli atl Coun[y ; Sll?RIsV E;RS};FOR F.XPLANATORY LANGUAGIi ordinances anA Stxte laws regul�ting Plumbing, and hereby � F authorize representatives of this County to en[er upon the ' � above�mentioited property 1'm'in pection purposes. � i � �G(� ✓� � ���-�`��6��---- � �Sigi�x re of Perm�ttee Uate �� � t. � p z c� � o �v 1➢ ° o�. , -n a .P G -� N�N G�t`"�v Y(71i `�q `1r`1� � � m � �,}u>,'.?J aC' � ; f�`1c�1 N � �t�`�-i'� .��i'D'O m� .1,. 1ot`� T�� �,m�D . . .�p'A�1 ' � Z... xy1M,� ,., 'W `Q•N T��! , p 1 �'m�1 ' �'�1�',� . 0 1 �i` �^ �', �'� , � `_ m1 y '1 �3`'� �� �� O ,� � ' Y � - , �'.m j `; � � s , ,� ; -..�', ' .�� !: .� F. �1 1 m 4 � n �` ,,�.� '�� ,,, � (h -'� " _� ' � � 1 N 1 p •- ,. � ;1 � 1 cn . • � . �' ' 11 ,Z� Z , r "4 p C ,'�n 1 1 fi N + , � j � � i � ` � ' � . � � � , � � � � ! � t �: . � � i j � , � � � 1 ! � , � z� � � � � � :� � � , ' � � � � �° . 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