HomeMy WebLinkAbout1226A A ION DECLARATION oewasaw � � � � I �
I hereby af��m that 1 have a"certificate of�on9ent�o se�f �Es„�=-eaa APPLICATION FOR PLUMBII`IG PERMIT �
insure,or a certificate of Workers'Compensa[ion Insurance,or . .
a certified copy thereof[Sec.3Bo0,Lab.C.)
��/� � COUNTY OF LOS ANGELES BUI LDfNG AND SAFETY
Yolicy . al Q3L�mpanY �
� � Certified copy is heteby furnished. FOR APPLICANT TO FILL IN-IPRINT OR TYPE) BUII.�iNG /�!'
ADDRE55 �(J 4- -
�Certified copY�filed with e county bu' � .nspect' NUMBER FIXTURE OR ITEM i FEE - �
Date�a� � Wq7ER CLOSET IOCALITV )�� � j�
App�icant NEARES7 �
BATH TUB CROSS ST. 1
CERT[FICATE OF EXEMPTION FROM WOR .R '
COMPENSATIONINSURANCE SHOWER OWNER �S `
LAVATORY MAIL /
('fhis section need not be completed if the work involved ADDRE55 ���d (.r. G S� }
by the permit is for one hundred dollacs (5100)or less.) SINK GTY � EL.NO, a
FW G J'' ,�AG/� ✓��fP—OSCi� p
i certify that in the performance of the work for which[his OISHWASHER CONTqACTOH �S� V
permit is issued,I shall not employ eny person in any manner
�
so as to become subject to the Workers'ComDensation Laws. CLOTHES WASHER A�DflESS � �� �
Date Applicant SWlMMING POOL FECEPTOR ! C�
CITY TEL.N . !�� W
NOTICE TO APPLICANT:If,after rnaking this Certificate of � }�({� a
Ezem tion, you ahould become subject to the Workers' LAWNSPRINKLER9VSTEM
P STATE LfC. tq
Compensation provisions of the Labor Code,you musi forth- LICENSE NO � CIASS � '�a� '�
with compiy wlth such Otovisions or this permit shall be NIATER HEATER —
deemed revoked. GAS SVSTEM OUTLE75 DISTRICT NO. PROCESSED
^� � `1
LICENSED CONTAAC70RS DECLARATIO�I OUTLETS OVER (/- ! C
I hereby affirm that I am licensed undzr provisions of Chapter 5 PER SVSTEM
4 (cammencing with Sectian 7000)of Division 3 of the Busi- FINAL VALIDATI�N
ness and Professions Code,and my license is in full force and DATE
eFfect. (_
License NumberQf��/�SE Lic.Class G���/ BY
Contractor�]tJ1�b.�,r,�ci�. Date 9—�lT�/
-'/' .J
� I am exempt from the llcensinq requirements as 1 am a PI3n Check f8e
Licensed architec[ or a reg�stered professional engineer pLUMeING PERMIT ISSUING FEE$ Z'j
acting in my professional capacity (Section 7051,Bus-
iness and Profession5 Cvde). TOTAL FEE � �1
L3c.or Reg.No. Date Plan check applicant
� HOn4E OWNER-BUILDER DECLARATION Name
:�� s����� �'.
I hereby affirm that 1 am exempt from the Contractor's Address ,. n r. e- ,.
License Law for the following reason(Section 7031.i,Bus3- Clty Tel.No. � c � <<,.(?
ness and Professions Code): �
� �I,as owner of the property,am exclusively contracting . ' ` � `��� ���
with licensed contrectors to construct the project �
� (Section 7044,Husiness and Professions CoQa). �,p � t.F f �
CN7N37RUCTION LEND[NG AGENCY
f herWy aff5rm that there is a construction lending agency
for the performance of the work for which thls Dermit Is
Issued($ec.3097,Civ.C.). -
Lender's Name
Le�rdee's hd�reaa
I certity 4hat i�have read[his application and state thet the
above information is correct.I agrec to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and 5[a[e]aws regulating Ylumbing, and hereby .
author'ze reptesen[ati�es f this County to enter upon the �
above cntio ed t - t ori tion purposes �
,�.a�.-� �� —�
ature of Permittee Date
_ _ _
_ t, , �
- - — � • _,_:��� a�fi1«.. -...w�+w ++�1M4
FtPPROVALS DATE INSPCCTORSSIGNATURE INSPECTOP'SMOl-EE�_ _ � � �'."ri..y`.��,' ,�. � ,
UfVDER SIAB WORK �
�ROUGH PLUMBING _ _^�, �R^�?''�'Y����"-����ittl��i'::erc:»,�t ffom tl:r.Cont[�CCos�S
7.p"eVr-� 7_w�l,a�Ei+e�1o1��,sirrp,ressxn(S�Hir,n 703I.5.
GAS PIPINfi. _ .���_ I�i sb:ces m_d frof r.'o ; Co.!_J. Ar.y rity or couttly
GAS VENT � � ' � . 1i�1;iCF; Y.r���lf�`. ¢ �:',"1":i'.' !rJ cU�;Sln:ft, c:fi'/, iiR�/ot'C,
HOT WATER HEATEfi � _.,___»_ �-'�r'�:,'''�;,��r��'r:,'�r Cr:y s'Sn:ClulP,priar to its issu�t:cc,
— , c's;*.rr.-,-�,�--er,,. ¢n�,i•cant for sucl! p�+'m.ir ro Jil[r a�
PLUM1f6M16 FI?F"fURGB � � � - � '�
� <irr..���.' �c�.r>crrtirr r?at 1�� ie 7ircve:r�1�!%arsa�crrr�ro the
s,aSTflS'r � .p�vF'iro�';of ti:.r Cotftrs�iori�l,icesssc Lnir (Chaprer 9
UTILIiv CO.NDTIFltO � (euF�racr.rt,��� u�%l:: $rsfi.�W 7�'0; nf Diad•:iors 3 af Yk�
� - . Gr*;r�s�, ar•,l 1';n;:>s^ro�is C`ode� or th.<�t he is exempt
�n� � � f��. c t ,'r:b..�-.fc�"II C�� �!ez�:� �fic� Ar�y
PINhL � - �� v��t.`i�i �f S-�ti�._, 7C1L5 bYc 1 av-i�li.�o- f��i aParmir
. ,. . � ___.—�--. --.�, s:�l.y'�.:ccr�,:-e,!;;•':r..�:t w r.crrif perr:lrv of nut more tl�srv
� � lm.�rt�.;;�.�,t,i du.r.,�.(�sCp�.:
�v 6'Fg�AGVFXOv�AC. ..• � � � .�-___._�, L]] a o���i.�-t f[i_pc�perty�v:l(co[-c u�prlc,and
tP._etr �tu..�:i.�t i S cd:d o=ot;cred fo[,ale.
. _. ' ' . . . . '_' _,_._, (S°'r. P --, Dirriw �;ae:' Pr'or srr r,u Cod�: Tlie Cai�
� ' ' - -- , rrc-tnrs J1�r:.;c I.�-r'ce€n�-nF��:v m a!i o�cner of
� . .. - . . .. � , — ------- ��;:;:::.;} .v, 0 6wi'-.;;�r irwprcoc.;tfz..rcur..c:;:t wke dccs
- � � � � _ s:k�ls � � F�'�.,.1; prc:���i� r;� sNch ir;:Fv��a�r+esr+rs
' . . . � � - __..___�. C+c v,�.�/ i+'-fu:;le�f nr ejfem�J Jar s�'!e. I.f. 7r:�tcecer. lJae
. .:•il''.�., r,r i:r:r:rncerrrert! i:: sold u�irh�� o�.e yem uf
�. . - . -_ __�_ cor:�.:r;':�;inn, t8� nwc�r-M:rt�k�r H�il! 1w:'e the burden
� ' � - - o(�-:n.;.�„' ; �: Jr� t.'id rmt L•url�ar rr:re��re f�s d:e
f:.
t��rl-ys����_:�:�.�
7 r..�.�.�r;n�c,�,',.r£_,. .
. . - . _'— . 'l1'[_Y.1.�'.fUT t�ll.i Ci;P:NH�,._..__.� —�
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IPA6P�CTOR'S NOTES � �