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Home My WebLink About1701 CLIFFBRANCH DR (2)WORKERS' OWENSATION01FOARAT1ON APPLICATION FOR PLUMBING PERMIT i I hereby affirm that I have a certtficote of consent to self 7 insure, of a cernftcafe of Workers' mpensanon Insurance, CE St.7 (REV. 1M81) or o certified COPY thereof (Sec. 3= tab• C.) COUNTY OKOS.ANGELES BUILDING AND SAFETY Y I Policy No. Cpmparry - Certified copy is hereby furstabed - 3 - rise APPUCANT TO Flu IN (PRINT OR "1*1 * i'%D ! _ - Cartified•copr is fled with the county building hapec- NUMBER fixnm OR REM - RE tan deparimem. _ iloca Y .0 ' Date Appllcont CERTIFICATE QQF EME141PTK)N FROIIlt WORKERS'9AT» ( C:0X$FNSAftGN tFIStiRANCE (Thlx t tlonmsednofbis cuntpletrid If flee werfc Involved by j ibe persnB ft.fbr aethuednsd do�Iaq (SfDO) or bn.) 1 certify char to the, WarmKince (if the. work for which this permit is issued, I shrift not emptoyarry, P@pon in any manner so as to be fee Wbfect to the Workers' ()mpensarion Laws. II Dots $ Want -•& - ` Nona TO APPLtC49YT: If, after making: this Carnfitor of exempnian, Yost shondd bacomer subject to the Workers' Compensation prasRtons of the• kabor Cede: yais must Forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS OECLARAnON I hereby affirm that I am Lkemo un(Ibr prgvisicre of Chapter 9 (ieommancing with SOTrion 7. jj of OIsision 3- of the Business i and ProfessloesCod4 and my, Ip�nM is in full force andaffect- /�� License Number !«a�'- Lic. Clan J contractorBY I om exempt under Set. A Lae ( B.&P.C. for this reason NEAR OWNER Hpb a y SINK ctrr .DISHWASHER _ CONTRACTOR ADDRESS �D CITY STATE t.ICENSE NO. / _ DISTRI - SS RR FINAL 'DATE - a FINAL /10's7 0 S'nnnture •. �'. u ra SHOWER LAVATORY CLOTHES WA$tER swtMMltic Pisa aECEvroR LAWN SPRINKLER SYSTEM WATER HEATER GAS SYSTEM OtrTltTs Plan check fee PLUMBING PERMIT ISSUING FEE $ WATER TOT/kl FEE TEL. NO TEL. i9�oe6 �407.5A 9•••.••5 ck ap I • • 1 6�.5 0 j SINGkE fAMICY HOME OWNER.64jIkDFR 0EC1ARA7lON • • • 1 (t 5.0 cisIhereby affirm that I am exemptfrom the -Contractors License.taw k:i for the following. reason (Section 703T.5, Business and Professions Cada): Te1.Nq. g'y'-/O 0A,04—B5 �. ❑ I, as owner of the property, will do the work and the I structure is not intended or offered for sole (Section ► 7W4, Business and Profpssicros Code). j CONSTRUCTION LENDING AGENCY 1 bomb, affirm that there is o construction lending agency for the performance of the wort fan which this permit is i> "d (Sec. 3097, CH. C.). Lenders Name jLender's Address - I ceral, that I have read this gpplioatian and state tlmt the ► above information is correct. I agree to comply with OR County ordinances and -Scale bws regulating Plumbing, and hereby 1, authorize represemoems of this Cuunty, to enter upon Ike- above-mermaned . rrq fbr irtapeerionpuaarpoaea I. / of SEE REVERSE FOR EXPLANATORY LAROUAM Signature o Pertain ate AFFROVALS DATE INSPECTOR'S SIGNATURE UNDER SLAB WORK ROUGH PLUMBING GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES GAS TEST UTILITY CO. NOTIFIED cc77 FINAL -G r�rr rx 51 INDUSTRIAL WASTE AFFROVAL INSPECTOR'S NOTES INSPECTOR'S NOTES OWNER -BUILDER DECLARATION I herehy affirm that I am e mpt from the Contractor"s License Law for the follawing reason (Section 7031.5, Business and Professions Code): Any city or county which requires o permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also re- quires the applicant for such permit to fife a signed state- ment that he Is licensed pursuant to the provisions of the Contractor's License Low (Chapter 9 (commenting with Section 7000) of Division 3 of the business and Profes- slons Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7037.5 by any applicant for a permit subjects the appli cant to a civil penalty of not more than five hundred dollars ($500).: ❑ I, os owner of the property will do the work, and the structure is not intended or offered for sole. (Sec.7044, Business and Professions Code: The Contrac- for's License Law does not apply to an owner of properly who builds or improves thereon, and who does such work himself provided that such improvements are not intended or offered for sale, if, however, the building or Improvement is sold within one year of completion, the owner -builder will hove the burden of proving that he did not build or improve for the purpose of safe.) 1 am exempt under Sec. B & P,C. for this reason Date Owner