HomeMy WebLinkAbout1729A _� __ _ � --__ _ �s -��a..__. .—. ... ._ . ..
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WORKERS'COMPENSATION DECLARATION �awee�w � -
I hereby affirm that , have e'rertificare ef consent to 8e�e ce en,=-.o, A P P L I C A T I Q N F4 R P L U M B I N G P E R M I T �
insure,or a certificate of Workers'Compensation Insurance,or
. a certiLied copy thereof($ec.38D0,Lab.C.) /' COUNTY OF LOS ANGELES BUILDING AND SAFETY
PaiicYN�L" ��C�penYy/�LII �C.� .�
� � Certifled copy is hereby fumished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDWG �
ADDRESS
� Certified cupy is filed with t county bu' i Inspe t' NUMBER fIXTURE OR iTEM • FEE
Date�d r e WATER CLOSET LOCALITY . � .
.L Applicant NEAREST
� BATH TUB CROSS ST. � �
CERTIFICATE OF EXEMPT[ON FROM WORK 5' �
COMPENSATION INSURANCE SHOWER OWNER .
LAVATORV MAIL }
� (This section nead not be completed if the work involved AOPRESS a
6y the permit is for one hundied do{lars ($100)or tess.) SINK ' �
CITV TEL.NO, U
I certify that in the performance of the work for which this DISHWASHER / �
� ermit is issued,I shall not em lo an erson In an mannet CpN7RAC70R
P D Y Y P Y I SC_ - O
so as to become subject to the Workers'Com➢ensation Laws. CLOTHES WASHER qDDRESS 1 � ' /�
DaCe AD➢>icant . �
SWIMMING PDOL RECEPTOR
NOTICE TO APPLICANT:IC,after making this Certifcate of CITV TE�.NO ,,,,� y
Exemption, you shauid become subject to the Workers' LAWN SPRINKLER SYSTEM Z
� STATE LIC. —
Compensation provisions of the Labor Code,you must forth- yyqTER HEATER LICENSE NO. � � CLASS �`�
with comply with such provisions or this permit shatl 6e
deemed revaked. GAS SVSTEM OUTlET5 �ISTRiC�. PRO`SSED eY_
�
UCENSEDCONTRACTORSDECLARATION OUTl.ETSOVER �� V
I here6v effirm that I am ticensed under provisions of Chapter 5 PER SVSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code,and my license is in full force and DATE
effect. s
License Numbe �� Lic.Class �"—�� . . gy ` � .-.;�'�,,.
Contractor�D�o D�{_ Date��l�(""� 1 � c �. e c,_
❑ ��
1 am exempt from the]icensing requirements as[am a Plan check fee
licensed architect or a ragistered professional engineer �c- ti
acting in my professional capacity (Section 7D51, Bus- PLUMBING PERMIT ISSUING FEE$ �� � � � • � ..: .. i.
iness and Professions Code). TOTAL FEE � � . r��� • i � �� ��f:
Lic.or Reg.No. ➢ate Plan check epplicant � �_y 1 �;�..n �
HOME OWNER-BUILDER�ECLARATION Name � �
I hereby affirm that t am ezempt ftom the Contractor's Address �
License Law for the follovring reuson (Section.7031.5,Busl- p�ty Tel.No. �
nesx artd Professions Code):
I,es owner of the property,am exclusively contracting
�, with licensed contraetors [o construct the project
(Section 704a,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work fo� which this permit ia
issued(Sac.3097,Civ.CJ. �
Lendee's Nome '
�_ Cmdev'�Addteas
I certify that 1 have reed this application and state that the �
abuve information is conect.I agree to comply with all County SEE REVERSE FOR EXPLANqTORY LANGUAGE
ordinances and Siate laws regulating Plumbirtg, u�d hereby
aut orize representatives of this County to en[er upon ths
abo -mentione propert t or inspecHon purposex.
` I ��Q r
ll
Signature of ermit e Date
.. �t � — �-1� ��' '��..� . ... ����~. . .
��. . �'i� .,—__�� �r�:1
APPROVqLS DATE INSPECI'ORSSfGhMTURE �NSPE�TOR'S NOTES ��_V � (?"�',';,;t:i:-1��JILBi:P,I�LCL.'.P4;`aTl�t
UNDER SlAB WORK . �
ROUGH PLUM9IMG �._�__ .. ��.''=+::':�y nfGrn•:t1:a[I am c�en��t from[he Cnr.trac[or's
- Liccn�.e C�c� fni t!1� i'o!(m,;ing resson'/SeeNan 70J1.5.
GAS PIPIPiG . . .
pu:,,...e�c c:�:' 7'rof r:ra"; Co:?eJ: ;tny ci�y or co��rq•
C,AS VENY � ' � � � t:�7.dri. rcc�u,-e:; n p��=�ci; to cuns�nte[, a(for. in�prove.
HOTWATERHEATER � „ ._�__.�._.. G,:r.:�:,':��:�,ar rc(';�:'t'i:�'.5tnlct:rrP.plior f0 ils tSSteINi"f.
PLUnaatwe Fix7unr8 � .. � r..n.r,= . hc c+.r.'.:-sru jar suc7� pcnrzit to frle a
. .ay�rrr +r �-r tn.:i t�t he is lrcerH�'d petrt+rnt to the
� GAS TEST �o,��oisL���r ef Y.r' Co!'rmrtor's Liren�se Lew/Chapter 9
uTivav co.NOTirieo �_ /cor.:=:;-ecr.r.. w�ia1: Scedor; 70q0/ oI Di„rsior. 3 oj uie
.. „ £;�;in_::•� a=�s' ,'t�r,•fr�si.,�:�: CRd••J or thst Gc is caempt
�� � ��� tl �J,^r c-�i1��h �rr for tk-¢�fc ed exe� nYion.dr+7,
FINni. � � � �� .r.�uinlc. .:.,� G3LSb3'ara}c�,o'.'ca.itforapennif
su�yccts t�:e c^,^i;cm�t tn a civil per�o�ty nj not��.arz tl;un
IN9l{}�TFYqA� . . � . . firc��:tn'.�e:'daf:�v�s/;SOflJ.:
aefiH A�PqbVA� - .. - . . Ll I.a-.o��rsr of thc pcopettYµill do ti;e wnrk,and
tt�.sKuctu-r i:nof infer�S_d or offeed fot sale.�
. . � ` � � � .--- (�-e. 7(':1. G:r,ir.rs�ur;J Pra.(cssior;s Cod.: The Con-
. � � trc^ln.�i Lirr;E��� I.ew ducs i:�;apFly m �i: owrter af
, � _ . ' ' � � � � �.— l:��F'.en o Fwr':1��- n•ry:rn�e. tf:creort,r�r�d irlro docs
'-. .. , � �� s_:�!: irar`_,.ki=:;rl,� r:or;,!�d dxst s.:�fi irrry�ruvc+ucnts
. � . . . . _...—.---- a�-.c r:n.r ir�tr�.:';d nr cfj�ve;.Jo:s,r'e. Ij, lsowever� tfre
- - f,_�i(_lri�� u� ir_;�rocei�+ei�t is suL.' H•ia1r:N o.w yeer af
_ - � � � _____._,___� rcra!'7:�;i�irz. tfs^ nu�rt^r-h.;rL/rr wi!i i;cre Ll;e bt:rdetl
� � � - oi P..o�.'�„r" fir�t ke di:: not L:�ild u;iutt>rove for tlte
—_ 1•;, .�nl�„�.)
�zs::e�.�,�:pi u!�,der S_�c._ ,
� F F [,:.for thi,rca�cts 4
. .------ Ia.%c___�__— � _
� � � vrn;e:�—��_
IM6PECTOR'S NOTES
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