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Home My WebLink About1701 CLIFFBRANCH DR (6)WORKERS' OWENSATIONOECLARATION APPLICATION FOR PLUMBING PERMIT i I hereby affirm that I have a certtlicole of consent to self 7 insure, of a certificate of Workers �,ompensarfon Insurance, CE dt7 (REV. 1M81) or o certified Copy thereof (Set. 3= Lab. C.) COUNTY OKOS.ANGELES BUILDING AND SAFETY Y I Policy No. Company - Cenified copy is hereby fnm4)rod - 3 roll awLicAlur ro nu IN (vtBNr aETYVEt * /70 ! Conde on mr is fled with the cauniy building Trager- tsUMBER MMIRE OR REM rEE tan depgnmem. ' Dafe Appllcont ! CERTIFICATE QpF EME141PTlON FR011lh WORKERS' I C:ORSFNSAfrGN tFIStiRANCE (Thlx s tlonefsednefbis icra: leted if fbe.werfc Involved by j ibe persnB ft.fbr. eethuednsd do�Iaq (SfDO) or bn.) I certify that to the Warmancer (if the. work for which this permit is issued, I shrill notemptayGTry P�jion in any manner so as to be fee Wblett to the Workers' (�mpensarion Laws. II Data 3' , Want _.Q - ` Nona TO AMUINT: If, after making: this C3ettliieor of Exempnion, you shondd become subleo to the Workers' Compensation prasfstons of the• kabon Cad*: YOD must Forth- with comply with such provisions or this permit shall be deemed revoked. UCENSEG CONTRACTORS OECLARAnON 1 hereby affirm that I am Bcens ua(Ibr provisions of Chapter 9 (ieomman % wihh S*Trion 7.Q(fQ) of Oisiiion 3- of the Business i and Profesria*sCod4 and my, le�rim is in full force andeffect /�� License Number �«a�'-� Lic. Class Contractor I ism exempt under Sec. A�GfVriLoe ( B.&P.C. for this reason ! 9ATIi TILB -*NEAREST CRIDiz ST OWNER Has a y SINK CITY .DISHWASHER _ CONTRACTOR ADDRESS �D cm 602 STATE L.Iown NO. 1 / _ DISTRI - S "R FINAL GATE - a FINAI BY S'nnnture •. u ra SHOWER LAVATORY CLOTHES WA$tER swtMMlNc rocx RECEPTOR IAWN SPRINKLER SYSTEM WATER HEATER GAS SYSTEM OlrnErs Plan check fee PLUMBING PERMIT ISSUING FEE $ WATER TOT/kl FEE Ta. Na TEL. %70'"6 �407.5A 9•••.••5 ck I • • 1 6�.5 0 j SINGkE fAMICY HOME OWNER.64jIkOFR 0EC1ARA7iON - • • • 1 fx 5.0 cisIhereby affirm that I am exempt from the -Contractors License.taw k:4 for the following. reo•an (Section 7031.5, Business and Professions Cade): 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 ► 7044, Business and Professions Code). j CONSTRUCTION LENDING AGENCY 1 bomb, affirm thot there is o construction lending agency for ! the performance of the wort fan which this permit is t "d (Sec. 3097, CH. C.). Lenders Name jLender's Address - I cerrtFy, that I have read this application and state tlmt the ► above information is correct. I agree to comply with OR County ordinances and•Stale bws regulating, Plumbing, and hereby 1, authorize represemoems of this County, to enter upon Ike - 'Is e-mermaned . rrq for irap*t�ianpuaarpoaea I. / of SEE REVERSE FOR EXPLANATORY LARCUAOt Signature o Vermiti 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 1 am c mpt from the Conxccror"s License Law for the following 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 end Professions Coda TheControc- 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