HomeMy WebLinkAbout1722A (19) WOR[CERS'COMYENSA'IION DECLARA7ION ]M867Y i
I hereby afPirm �hat � heye �rcertificate ��consept �ase�f �E.,�,s-.e, APPLICATION FOR PLUMBING -PERMIT {� �
insure,or a certiCicate of Workera'Compensation Insurance,or - ' . - �� I
u certified copy thereof(Sec.3800,La6.C•) �
COUNTY OF LOS ANGELES BUIlDtNG AND SAFETY
Policy No. Company , ��
� � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE1 OUILDING `���;l�� lr}�uNr „ 7/�� �
Certified copy is fited ' e o n y building inspection
NUMBER FIXTURE OR ITEM • FEE AO�RESS O� �/ /�' '��O t('
e arLF ent. WATER CLOSET �OCALIT �����J v?�-;
a � pplicant - � MEAREST � �
BATHTUO CROSSST.� � �
CERT[F[CA7E OF EXEMPTION rROM WO ERS' .
� COMPENSATION INSIIRANCE � SHOWER 6WNER • �,� �j��.r -
IAVATORY MAIL / r� /�� }
(This saciion need not be completed if tke work involvevl ADDRESS� ` U/�/V�`� (�' ,� a �
by the peimit is foc one hundced dollars ($1Q0)�c less� _ ,
SINK CIT '1 ,.�i� TEL.N05�� 7�� U
1 certify that in the perfotmance of the work for which this �ISHWASHER - �
perm#t is iss.ued,1 shal)not employ any pason in any mannei CONTRACTO / U..�J ���� Q �
so as to become subject to the Workers'Compensatiou Lxws. CLO7HE5 WASHER /<6. � - ,_^� f� r U
: Date Applicant DRESS��,J W �
. SWIMMING POOL RECEPTOR a ;
NOTICE TO APPLICANT:If,after making this Certiticate of CITY `� �{C�. TEL.NO3����� y
Exemption, you should become :ubject to the Workers' IAWN SPRINKLER Sv5FEM 5TATE �7 LIC. � �i
Compensation provisians of the Lahor Code,you must forth- yyqTER HEATER LICENSE NO.f G I 7�7 CLASS ��� i
with comply with such provisions or 4his permit shall be
deemed revoked. DISTRICT NO. PROCESSED BY
GAS SYSTEM OUTLETS
LICENSEDCQNTRACTORSDECLARATIQN OUTLETSOVER � lCl ,�4�f �
I hereby affirm that I am licensed under provisions of Chapter SVSF - �
9 (cnmmencing with Sec4ion 7000)of Division 3 of the 8usi- .� FINAL VALIDATION �
ness and Yrofessioris Code,and mY�icense is in full force and DATE 'L 2`�7L {
effect. tr...,� �
License Nurtbh• Lic.Classc,,� FINAL �
L ` BY �j(�1�2y �
Contract - Date ���'e_ o��
� [am exempt from the licensing requirements as I em a Plan check fee �
licensed archilect or a registereQ professionai engineer pLUM91NG PERMIT ISSUING FEE S
ac[ing in my professional capacity (Section 7051,Bus- :S1J �
irtess and Prnfessions Code). TpFAL FEE �j S� �
- Lic.or ReK.No. Date p�en check appficant
i
HO�tE OWNER-BUI6DER DECLARATtON Name � �-� � � - - � � - ��I-�-2 2 A---- �
I hereby affirm that I am exempt from the Contractor's Address�- � -� - � - � � � � �- -- � �� #� • • • •5 �
i
.l License Law for the following reason (Sec[ion_7031.5.Busl.- Cisy � � TeL No. � • •2 Q 5 C �
� ness and Protessions Cude): � •
;�� I,as owner of the property,nm exclusively rontra��ting � � � �� • •2 Q 5�� �
with licensed contractors to eonstruct the project
(SeMion 7044,Business and Yrofessions Code). . . . Q��3_$2 �
i
� CUNSTRUCTION LENDING AGENCY . � � � �
[ hereby sffirm thal there is a construc[ian lending agency
.for the performance of the work tor which this permit is �
issued(Sec.309'7,Ciy.C.).
Lender's Name E
f
Lender's Address �
I certify-that I have read t application and state that the �
above information is correct.7 gree to complY with all County SEE ltEVERSE FOR EXPLANATORY LANGUAGE �
ordinances • d S e laws re ulating Plumbing, and hereby
authorize re resenta ives af is County to enter upon the i
above-menti ned pr or inspection purposes �
/ I
U �- - � �
Signature of Permittee � Date j
�
y�^ �ci O��C S O� � �=C O C �O N � �O Y S � ..
O O `�"' �
•.�.n�, 3 � y�� �^a •� �� � V ry'Cs �' � o � �
r C � 4._.°'�,'�,� v ..: y G X y O ` � u,
r. �+ � r^� � '� ,S. 4' _ �"". 'ti
` h � cco t� s
7 � + � ti ,_ �`_ � ., �. � � � � z � r ^ � �
J ... � ._ d C Oi C v u •. � ..
O J V � ~ �'�' ` $'H S Cl +�-r fi y w1 � ':1....O � .V C
� _ .�e � � d.� x � y �z �� _ � � .
�_ � � � � � � � � � �.
. d �E C � ` c C„4.�C,�Tt' `�cv.V �.,i `�^~ r a
e1; O .� r i ^t' "`'� pco�`� �^7 ` °i'� ` C , ' ' .
a 4.. �� ^ i`" ti G U i y q Ci :: � O.-� b 'V � , "
V G � .. �' � " v V� O O '' - T,` +; p „'� y S = I .
q � �i..�'_, � � p _�n C�� ��. F� � �' ~�;.,~ pl L I , .
`,�',�, � ° ;"� _ ^ o �c' - •�`i yt ..�" .� .
� ' �' ° y � `^ � C. '` .� � � � ,. ?. I�i ., i ; �
� E � _ � : ,J�• c, � �°.^ o -, - t, c - _< .' .i: •r � I .
�i' '� C a`�. _ . �� : U rv. � _.� Y ,� „^�4� S; y, `� �° I
O .� r + r ' : '..: +..�� �' l7 ��4,:'G. �� : ... �
a � •F ': r[1 o`a � a'C o C \;�`. '- �... .. .,.. ;� .. „ I I
� C: _Gi 'L. y' �.'�.�� � ,C` � S: : :', �: `•t `.., ` :.i C� �
�" `ti cv cV.. �� " c, i -' .� ( I I
� ~� FC., ❑ �� G ' � � � i• .. �
. .: ¢; " c1 e, �
C4; F . y, � ^ �c' �.: •� Y �., ; n c:_ ' i I
� r� i y ~ ; 4-.G.. �=�: c: �'C'-�. c: � _r.': ' �" � , . .., i I
I'f. ;"`.; i C' C'. ^" tl�.., :� - ..:U ,.. - L ~ ^: i �
?; � '- `p '<; b C s: ti "'7 . i:' ,_ ., "G-- �� ". . L . '
G _ ` � ,. r. ; -- c: � � Y: _ �, r._ ^ '' r..
� , �-�: .; o �.-'� � .. 1.
1. L � _ y� c� " : C%�'"U` .v ~� v. 5: '`''�' {` ... ' C' ' ...., C.:� � ,... �. , .
� - < <7 O � �, •c`; 'o r_� ', ci c, � _ . .
� .� � U.; � � _ �.
... .� . .� � � ...�_G:; ... .. ,.,4:� �. .. .. .. ._ . .. .. ....
' � � � I I � ' � I ! �
� I I � � � � � � ! ; � ,
� I � � , I
, � - ' � , I I
'. I ' I I 1
� ! ' � � � i
w ; � � ; i � � I
o I i
� ' � I � � ' � � I I i �
° ; ; I � � � , ' t � ' ' j i
� � I � � ; � i � !
z �; ; ( � I
— � �� , I, � I � . I
� , � � � i i i i �.
i i i ' , I I �i i
t , i i i �
i � i � I r � I �
� j i �� �� � � � I i I � ' � i ; � I
W
�
�
�
Q
Z �
N �
N .
¢
O �
�j ' tn
a � w
N ~
Z �
— Z
I. �: �, �'j �n
w I OC
Q i a O
H
� � U
w
�"� j -T �I �. _
z ,
I
" ���I i° �a � -
� � � -
y o z� Flo� LL� a
� 3 m a.� r >
am � w�� o i . o _
> a � x;x Z � ��o�
O J J � �;¢iLL I iQa
� Ul� o- Z Z:W�(7 � �� i OC Q
a a[ x a w Q Z w•}; � ;I-w i
Q w [7 a > ��c. I-IF_i Q � �;� . i
2 O Q Q O � a,F-� � �Q
���I� � S'oI�'�I I LL � Z3
���r���i.