HomeMy WebLinkAbout1228A �
�
WORKERS'COMPENSATIONDECLARATION )6A68)A APPLIGATiON FOR PLIIMBiNG PERMI �
1 hereby affirm that I have a certificate of consent to self ce eiv(z-ea� .
insure,or a certificate of Workers'Compensation InsuranCe,or
a certified copy thereof(Sec.3800,Lab.C.)
PoI;�Y i,{�Ba1 lv3�' UNI '—G�"RI� COUNTY OF LOS ANGELES BUILDWG AND SAFETY
ompany
I � Certifled copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OF TVPEI BUILDING
ADDRE59 �
�Certified copy is filed with he county 6uildin i pection NUMBER FI%TURE OR ITEM • FEE
�jqpa e ` LOCAUTY
. Date"� ' � WATER CLOSET
Applicant NEAREST
BATH TUB CROSS ST. �
CERYIFICATE OF EXEMPTION FAOM W RKERS'
COMPENSATIONiNSURANCE SHOWER OWNER '
LAVATOFiV MAIL
(This secfion need not be completed if the work involved qoociesS
by the pe�mit is for one hu�ced doLLazs (5100) or less.) >'
SINK CITY TEL.NO. O
I certify that in the performance of the work for which this DISHWASHEF j J C.)
permit is issued.I shall not employ eny person in anY manne� CON7RACTOR ` �y
a
so as to become subject to the Worke�s'Compensation Laws. CLOTHES WASHER ADDRESS � d I � fE. O
Date Applicant ��� �
SWIMMING POOL RECEPTQR � O
NOTICE TO APPLICANT:If,afier making this Certificate of CITY � � TEL.N �'" W
Exemption, you should become subject to the Workers' LAWN SPR�NKLER&YSTEM aU gTATE y� LIC. ^� (6A
Compensation provisions of the Labor Code,you mus[forth- WATER HEATER LICENSE NO� J CLA55 �'.C.� Z
, with comply with such provisions or this permit shall be —
deemedrevoked. GASSYSTEM OUTLETS DISTRICTNO. PRO�ESSEDBY
LICENSED CONTRACTORS DECLARATION OUT�E75 OVER G^^— C C��
1 hereby affirm that I am lice�sed under provisions of Chapter 5 PER SVSTEM .
9 (commencing with Section 7000)of Divis3on 3 of the Busi- FINAL VALIDATION
ness and Professions Code,and my license is in full force and DATE
efPect.
License Number����"� Lic.Ciass �'�'01-�
Contractor��i_ Date �'���'(l f
� , - �,,f-
� I am axempt Srom the licensing requirements as I am a Plan Check fCe
licensed architect o� a tegistered professional engineer p�VMBING PERMIT ISSUING FEE$ � s..�1 � �'.L,
acting in my protessional capaCity (SeCtion 7051,Bus- �•- ��
iness and ProSessions Code). TOTAL FEE (a ;'a. ' u n-» (;
� Lic.or Reg.No. Date Plan check applicant � G��,1 �c:�
HOME OWNER-BUILDEIi DECLARATION Name r � ��. r.:��:r
I hereby effirm that I am exempt from the Corttractor's Addreas `,�,� 11_�;
License Law for the follow�ng reason(Section 7031.5, Busi- Cicy Tel.No.
ness and Professiorts Code):
� I,as owner of the property,am exclusivety contraCting
with licensed con[rac[ors to ronstruct the projeCt ,
�, (Section 7044,Business and Professions Code).
COSdSTRUCTION LEN➢ING AGENCY
I hereby afFirm thet there is a construction lending agency
for the pnrformance of the work for which this permit is
»�m Es�.3a�.e��.c.�.
' Lender's Name
Lender's Address �
I certify that I have reed this application and state that the � .
above information is wrrect.I egree to comP�Y�+'ith ell County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State lews regulating Vlumbing, and herehy
aut rize representatives of th's County to enter upon the �
a6o merttionad sty f �pection purposes.
Signatura of Permit e Date � �
_
_ __ _
. � .� �.�. •- - -- _ - -__ - _ ___�._.__..._y.....__ _ �
..��..�.s.� .
APPROVALS DATE IN9PECTOR35IGNATUR[ IfiSPECTO�'S P;OTE�..�.M_�^�_�......0 �',"_._.':-t:;.';LEi�:�L D:.l�LARr�FIOi\�
'UNDER SLAB WORK
h^�OUGH PLUMBIfV6 . __ i 3'cr-t)y'+d�i;;re tF,y{1�^�ev^maf f�t0le:t1iC�'Onti3CfOi�6
GAS PIPIfi6 �i " L � C:r't7 Cn _wm�r-�wn(S�elinn 7C3L5,
� ____—_____ f . ., u�:� Fro;;s...i,., Ccd/. .-1 ny crt�� or rouriry
GAS VENT� � -- «'Lirlt��rr.:J.Ji;rs c penr�it to cmtrtract, oltc;�, irr;prarc,
HOT WATER HEATER �--� --. ..�_�_._ U.'%;:^:�:1;, vr r.�:::"r c:�:}'.c7;:ctrrr'r,Fri�r fa its i.^,.v��rQ€cfe,
u�6 FIX7UF�ee . � . . � � cica rc:,icirc.4 tF:r eppii�m.t for rcrh perrt�it ro..filc a
_—. ___.� ,.;�r�'+ �...'�'rr+i+.'��r lls�r hr is 6cP�med purwK;tY[o the
�a5 reST prarr:rec; of t?;., Cor:!r,��to+�'c I,icerzsc�Lew (Cha�vter 9
UTILIfiI'CO.NOTIFIED — �r,�=lt:-.�'+:'•i::•; wi1!t Scrtier, 76CG/ of Di�SsirY�+ 3 of fhe
. r,::i�.:.:s r.rr? Prot�s�?ro,�s CaA:�J or 11.�.r., hc is exen:pt
.------., u re : 5c h.:ic jor t�� a���'d exar..�tion._4ny
F i ndlsL �'�s�ed O� �� � . r �"_� �f ��r�r::ur 9071.5 hJ'c 3 M'A�:"art f u a 1?�'rrnir
s:�L%rr't��!L�c':';;^n::t!o n rieii pe�t<y of nn:more iltan
IND TRIA � . � frv��hur.L�+;d[i✓IJz���.r(SSOCJ.:
AB�E�VAL . . .. --- �.—_— O i.ss u•,.r,.r nf 1h�pcvperty x�il!do the uotk�aad
tbe stu:u[ucc i>nx�:'u,:�_r,Jcv?ae offcred fu[sris.
� - � �� � _ (Sec. 717�;�1, E1�-ri�:rrs ur.r!Pra'cssinr:s Code: Tlfe Con-
. . - , . rr:-rtr.��'s Li.xr.�s� Lciv�'u-s rtor�;7tiv to air ox�r:er of
- � . . � . �. � �_..,_ .____ 1 .�:'rtx � �_ t.;�'�c n: i c;•ro,-�;tkcreat,re�u!wlio does
- . .. � s;:c'h i:xs-,, lu�;;:�;` �:��r�idc:.� 1f:ai s::c{a irnp�e�vemer,ts
. . - -- --- -- cdz� �ux ier.ur.'.��'o.r.fJr,-��tf ftir s.:1e, If, lwwever. tke
h�;t'rrr;• or iP�.,a,�rrz�:_�t� is suld witln�r: � ��cw+' of
� � - - , �_��...� c�,r:�nx-tir�;:. 7f:r nu<<.e.��-baJdf; w•ifi hst�e rl:r bttrden
. . nJ r-ori��,� tlr.�t L_ dr_I r,ot 7rai1�'or rr;:,�roca for U�e
--_ r=� .�,�.. �
� � �:�::c��.�:::�.-f r.r�icr�=c. ,
S�F.i^.l.f0:[f1i91'�7tis?i» _
. -----------_._..._--- LF::',c..___..-----
� . . ._ — �'.'i;.�__..._.._.�._._..__,_ __
IM1�ECTOR'3 NOTES �