HomeMy WebLinkAbout1114A �� WORKERS'COMPENSATION DECLARATION qpPLICAT141�1 �CyR PLUMBING PERMIT
. I hereby affirm that I hove a certifimie of consent to self 76A667A
insure,or a certificafe of Workers'Compensation Insurance, CE 8n(REV.10/81)
or a rertified copy ihereof 5 . 9pc7 tab.C.) • �QUNTY OF 40S ANGELES BUILDING ANO SAFETY
��Y No.sa�-b+a����� G�tea� Qtw�.Y.caK �i��'^�t
',� Certified copy is hereby furnished. BUIIDING �1 �'1 �f A
❑ FOR APPLICANT TO FIIL W�PRINi OR TVPE) pDPBE55 !. .f. l7
Certified copy�s filed wi�h ihe county building inspeo NUMBER FIXTURE OR tTEM (� FEE
tion deporiment. lOCkIITY a
Date Appli4ont WATERCLOSET �
NEAREST
� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB � - CROSS ST.
, COMPENSATIONINSURANCE SHOWER- OWNER �
(This s�etion nod no1 b�eompbbd if th�work lavolwd by Mq�� ,�"' �Na
• 1h�p�rmH ia for ona hvndred doilerc(S��O)ot Ipc.) LAVATORY ADDRf55 � 7 �
���� I certify thot in the performance of fhe work for which�his �SINK ��
. permit is issued,I shall not employ any person in ony manner CITY ��NM�. TEL.NO. ,�
� so os to 6ecome s�bject to the Workers Compensaiion lqws_ OISHWASHER
CpNTRACTOR �
� Da1e App�icant - CLOTHES WASHER AD�RE55
� NOTICE TO APPLICANT: If, af�er making this Certifim�e of e�' V�
� Exem tian, ou should become sub'ect �o the Workers' SWIMMWGPOOLR(CEPTOR
p y I CiTY �. TEI.NO. ,yZZ�
Compensafion provisions of fhe labor Code,yoo must forfh- LqN'NSPRINKLERSYSTEMI
" with comply with s�ch p�ovisions or this permit sholl be STATE �� Q2� UC.
� deemed revoked. WATER HEATER LICENSE NO. CLA55
LICEN5ED CONTRACTOR6 DECLARATION �ISTRICT NO. ED BY
I hereby offirm ihaf I am licensed under provisions of Chaple�9 GAS SYSTEM OUTlETS '/\ �� q� r
V
� (commencing with Section�000)of Division 3 of Ihe Business Ol1TLET50VER � 6.
' S PER SVSTEM
and Profassions Code,and my license is in full force and effect. FINAL � VALIDATION V
� �vk,�.z, aa DATE J�3 �
License Nu � Lic.Closs� �
� a� fINAL � �
� Contracror-��.�(��°te�T� BY V
❑ we
I am exempt under Sec. •�'//C�p:r ��i L�:1c;�� y',d'UC.� �
8.8P.C.for rhis reason Plan check fee ��
! �°�e' PLUMBING PERMIT ISSUING FEE$
�0 �
' Signoture n_
� TOTAI FEE .,�,�
� �1114A
, Plon check applimM
SINGLE FAMILY $;��•� • ' • �J
' HOME OWNER-BVILDER DECLARATIQN Name
I hereby affirm ihot I om exempf from ihe Contractor's License � � v`C'��
�� Law(or the following reason(Secfion 7031.5, 8usiness and Address _
' Professions-Code): Cify Tel.Na. • � F is�F('i�
❑ I,os owner of the property,will do the work and ihe Q �.C Q`E�;.
� , strucfure is not intended or offered for sale (Section � � -
. 704t,Business and Professions Code).
��. CONSTRUCTION LENDING AGfNCY
, I heraby affirm that there is a construtlion lending agency for
ihe pehwmance of the wwk fo�whkh�his parmi�is issued
i (9es.�FA7,6ir.6.). � �
' Lend'er's IP¢me
' lendii'i�a8s �
�'. I certify lhat I hove read this application ond slate tha�ihe �
a6ove information is mrrect.1 agree to comply wilh oll County
ordinancas and State lows reguloting Plumbing,ond hereby
nuhhorize represankotivas of this County to enier upon the
above- ntioned propert for inspection porposes.
p/�� SEE RHYERSE FOR ERPLANATORY LANGUAGE
Xiltiii �'YI�YY�� /—�C�—/j .
- • "$ignnhiro o1 Perm+Has �afe �
INSRSCTOF'S N0T85 ' . OWNER-E LQEq C�ECIARAIION
APPROVALS DA�E INSPEC70R'3 9ifhYRTiJRE . . .,.. . . . t ,� , „
UNDER SlAB WORi; � -� " �� ��� '
I'heraby affirm thot I am�exempr from�he Controctor's
RdUGHPWM8ING . lieense Law fo� fhe follawing reason (Section 703L5,
Gk5 PIVING - •�� � ��" ��- `� 9usJness ond Pro/essions Cvde1:Any cily or couNy w�6ich
GAS VLTR � - requJres a permH}o cansfruct,alle:,impro��•,demoli;h.
. , or repa7r any sirucfure, prio�to ils issuance, olso rc-
HOT WAiER HE4TER uires ihe c t for such r t fo file a si d stvte-
q oppfi n pe mi gne
PLUMBYNG pixTu� � - �. . � mon��iwl he!:licenaed Furwont ro the provisior.c o1 N,e
GASTEST ' � ' Contraelor's Lieense Law(Chap>lar�(com.mencing witb
UTILITV CO.NOTIFlE - �� � � Seefioa 7000)ot Divisiop 3 of the Susiness end Proles�
slom Cods)or}hat M is�szem�f iherelrom a-rd}he basls
. .. _ *r ' , . . . . �
c7 for IF�e alfeged sxemF�lon. Any viafaflon of Sccfion
FINAL�' .i .iire�on _Jronf 703I.5 by any appl(cant ta�c pe�mrf subjects 1he appfi-
- 1 , ttmf fa a civil p�nalty o{rtot more ihan /rve hundred
. . doflars(.&S00).:
INDUSfiRIRt �� ' ❑I,as owner of ihe property will do the work;cnd
WASTE APPROVM ; � iMe SMucture!s nW intsnded or offorad fcr sale.
(Sea.70+U,6uNnrss arrd Frofesslons Coder 7he Conirac-
... . , � ' , .. , „ for's LJtr�»s�Law do�c not opply fo an owncr of�operiy
�_ , who btNk+�s or imprMes/hereon, ond who does such
�•� " � - . work h/mself pravkled tha�t such improvwnants ore not
� inYended or o/fered for sale.If,hows•rer,the butlding o��
, , improvemenf is saFd withrn one year o{campfetion,the
� owner-bullder wlll hcve the bvrden o/proving thct hc drd
net bulld or Improw!er tfie purpose of scle.)
�
, t �
I pm e�empS u�.�—�._,
i., , s•
. � B 8 P.C.�for ihis raason
Date
i
Owner
� IP�i99�€TbR'S MOT6S