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Home My WebLink About0921A ��l�,r.� � �` � - - -�� - . "'°RKERS"`°"^PE"SAT'°"°E""RAT'°" qppLICATION FOR PLUMBING PERMIT {� I hereby,affirm�hat I have a certificate of consent�o self in- 20-0026 DPW aiB7 Sore,or o cerfiflcate of Workers'Com ensation Insuran[e,or p �6A667A P CE 817(REV.8i861 I I certi eo y.ther f(See.3800,Lab.C.) � � - �� ,) jli�,��p /1�l � - COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS � Pa�licy o. Campany�fT�-� �� , . � Certified copy is hereby fumished. . . . . � FOR APPLICANT TO FlLL IN(VRINT OR TYPE) BU�LDING /a � �`�,�� Certified copy isfiled with the county building inspedion o.DDRe55 deparfinent. NUMBER FIXTURE OR ITEM � FEE ��A��TY p� Dafe 7��"��o/ Applicant �/.7'TU�-d"� WATER CLOSET�TOILET; NEAREST �I""•O�� CERiIFICATE OF EXEMPTION FROM WORKERS' � BATH TUB CROSS ST.�� L O Y ST�'E�L � . COMPENSATiON INSURANCE SHOWER OWNER A�i�,�,lq.�/ �� (Thia sect(on neod nof ba complefod if ihe work involved 6y MAII fho pormit Is for ono huadrad dollar�(SI00)or Ioss.) - IAVATORY AD�RESS t certify that in�he performonce of the work for which this per- SiNK - � . mit is is5ued,I shpll nof employ any person in qny manner so � � CITY TEL.NO. as to become subject to tbe Workers'Compensation Laws. DiSHWASHER coNrRncroR S��1� LC .� Date Applicanf � � � CLOTNES WASHER NOTICE TO APPLICANT:if,after making�his Certif�cate bf Ex- - aooRe55 r7� 7 y/ em tion, oo should become sub'ect to the Workers'Com en- SWIMMING VOOL RECEPTOR p Y I . P � CITv ./I' 7E1.NO,�/�36 safion provisions of the La6or Code,you m�st forfhwi�h comp- �.qWN SPRiNKLER SYSTEM 6'.--- Nv ly with such provisions or this permit shall be deemed revok- � SiA7E LiC. ^� ed. � � � WATER HEATER LICENSE NO. �y� CL455 Ca'- LICENSEO CONTRACTORS DECLARATION - GaS SVSIEM OUTLETS DiSTRICT NO. PROCESSED BY I hereby affirm Yhat I om licensed under provisions of Chapter /v 9(commencing with Sec�ion 700p)of Division 3 of the B�siness OUTLETS OVER � and Vrofessions Code,and my license is.in full forCe and ef- 5 PER SYSTEM FINAL VALIDA ON r fect. � . - DATE � �� License Number y3i�yo Lic.Class C�-�7 y � GJ �' ',� Lds� 3-iy_9b i BY AL o Conirodor �'1'✓"G 0 fe � � � I om exempt under Sec . . ! WS e.6a.c.fo�rh�s�eason plan check fee ► 2 D°te' . PLUMBING PERMIT ISSUING FEE$ �) �i,v Signature ?OTAL FEE � b � �G921A SWGLE FAMILY p�an check a limnt HOME OWNER-BUILDER DECLARATION � PP �j• • a : o� I Fereby affirm thaf I am exempt from ihe CoNractor's License Name � � Law for the following reason(Section 7031:5, Business and � � � � • � E,v Q Professions Code): � Address � �� I,as owner of the property, wiil do the work ond the Cify . TeL No. • 4 a 1 t�v(�!_ strudure is nof intended or affered for sale(Sedion 704Q . Q 8,� �]—F}8 Business ond Professions Code). _ - . , CONSTRUCTION LENDING AGENCY � I hereby affirm thal there is a constroction lending ogency for � � the performance of the work for which ihis permit is issued '� � (Sec.3697.Civ.C.). . . [efRfatTICBfPPe �CAdCF 9 F�df118�6 � � I certify th6t t have read this application and state that the , above infoimotion is correct.I agree to comply with a0 Counry � , � ordindnms and Sfpfe lows regulating Plumbing,ond here6y_ . a�thoriza representatives of this Covnty to enter upon the above-menlioned property for inspettion purposes. -� �� _�,��' SEE REVERSE FQR EXPLANATORY LANGUAGE i Signature of Permittee � �Date - � , _ _ �, _ � _ , qPPROVALS DATE INSPECTOR'S SIGNATURE INSPECTOR'S NOTES OINNEFi BUILDER DECLARATION UNDER SlAB WOFiK I fIBfB6y effflril Ma! 1 MI 97t9111p1 ffO111 ihB COI11faCtOf'f ROUGH PLUMBING . LIC811a8 lilW f0�thB fOIlOWI11Q f98601� ($BCfIQR 7Q31.5, Bus(ness and Profesaions CodeJ. Any cRy or couniy GAS PIPING � ' WI1(CN requires a permlt to construcf, aker, improve, GAS VEM1T � � dB/110I%SII O! repeir any structure,prlor to its issuanCe, HO7 WATER H EATER afso reqWres the appJicant tor such permit to file a signed PLUMBING FIXTURES statement ihat he Is ficensed pursuanr to the provisiorts GAS TEST o/the Contractor's Ucense Law(Chapter 9(commencing with Secfkn 7000)of Dlvlslon 3 of Me Buslness and Pro- un�m co.HonFien fessions Code)or thet he is e�cemp[therefrom and the basis for the alleged exemptron.Any violatbn ot Sectfan 7D31.5 by any appdcant far a permlt sub�ects ihe appiF FINAL �'nEer on.�.oat . cant to a civi!penaMy ol not more than�ive hundretl �/8fS($�).-. INDUSTRIAL . ❑4 ae owner of 1he ProPe+IY witl0o the work,8tM thB WASTE APPROVAL � � 6iNCt111B 16 nOl IIIIB1W6d Of 01f9(Bd fOf 8916. (Sec.7044,8uslness and Professbns Coare:The Contrac- tor's License LaW does rrof apply to an owner of property who builds or improves the�eon,and who do9s such work himself provldetl tAat such improvements are not irttend- ed or offeretl for sale.If,hoWever,the builtling or!m- provement la sold w'nhM one year oi completfon, fhe owner-builder will heve the burden of proving that he tlitl not builtl or imprave�or the purpose of sale.) 1 sm exempt under Sec. B&P.C.fw this reason Date Owner IIVSPECTOR'S NOTES