HomeMy WebLinkAbout1423A BAiION DECLARATION APPLICATION FOR PLUMBING PERMIT �
I hereby afflrm ihat I hove a certiiimte ol consenf�o self 20-0026 OPW 6l87
insure,or a certificate of Workers'Compensation Insumnce, 76A667A
or o cer�ified copy rharaof(Sec 3800,tab.C.) ���`�` COUNTY OF LOS ANGELES DEPT.OF PUBI.IC WORKS
V❑olicy No.�Company�'�'1�. �-+^�v-�
Certifiad mpy is hereby furnished. /�
f-0R APPLICAM TO FILL IN(PRINT OR TYPE) ADDRE55 Z� � /c}/N
Certified capy is f' wiih the coumy buii ' inspec-
tion eporlm t NUMBER FIX7URE OR ITEM [�q FEE �«ALITY
po � AP��� � � WATER CLOSET NEA�E57 . � A .
CERTIFICATE OF EXE IflN F WORKERS' Bn7H TUB a CROu St.
COMPENSATION INSURANCE OWnIER ���
(ThtY uciion nNd no�b�compfrted if th�work fnvolwd by SHoweR
Ih�p�tmi}��;or om hondnd dolMrt(f100}or Iqs.) "� �qVATORY MAIL
A�DRESS
I certify thot in Ihe performance of the work for which ihis
permit is issued,�shall not employ ony person in any manner SINK Cliv 7EL.NO.
so as to become subjecl fo�he Warkars'Compansafion Lows. DISHWASNER
CONTRACTOR .
Date opplimM CLOTHES WASHER AppRE55 C�
�' NOTICE TO APPLICANT: If, after making this Cartificate of ✓
Exbmpfion, you should become subject fo fhe Workeri SWIryLMMG POOL RECEPTOR
�Compema�lon provisions of the Labor Code,you must forih- LAWN SPRINKLER SVSTEM CITV TEI.NO. �Z`
ith camply wi�h such provisions or this permit shall be SiqTe tIC. r,�
- deemed rovoked. WATER HEATER LICENSE NO. �J GlASS
UCENSED CON7RACTORS DECLARATION D157RICT NO. ESSED 8Y
I harsby affirm thar I om�icenaed under provisions of Chapte�9 G,4S SYS7EM OUTLE75 �
(commencing with Seuion 7000)of Division 3 of the B�siness OUTLETSOVER
ond Professions Code,and my license is in full forca and effed. 5 vER SVS7El�n fINAL 1�/� � VALIQATION d
License Number ����' Lic.Class DATE � O
�/� FINAL U
Cont�actor���'�"� Da�e gY � a
� h�
I am exempt undar Sac. ()
8.8P.C.for�his reason ' 0.1
Plan check fee � v�
D e: p�UM61NG PERMIT ISSUING FEE S �O �
Signature �
F TOTAL FEE
Plan check applicont
SINGLE FAMIIY
HOME OWNER-BUR�ER DECLARATION Name F� �-2�4 r� '.
I heroby aHirm�hat 1 am exempt from tha Coniractor's License Address � �+''� • e •�
Law for the following ieason(Sec�ion 7031.5,8usiness and
Profeuions Code): Ci�y Tel.No. � s o�Q,5(,�
❑ I,•os owner of fhe property,will do tha work and�he - . .,
shucturo is not imended or offered for sale (Saction � � • `` `'�'�����-;O�
7044,Bvsiness and Professions Code).
CONSTRUCTION LEN�ING AGENCY �Q O �_��\
I heroby affirm thar ihare is a consrruction lending ogency for
the performante of�he work for which this permit is issued
(Sec.30A7,Civ.C.).
I�;p's - —
Lendv's Ad[tt�� ----
I cerrify thot I have read this opplicaiion and stale Ihaf the �
abova informo�ion is correct.I ograe ro mmply with all County
ordinontes and Slafe laws regulaling Plumb�ng,and hereby
aurhorize rapre�sentatives of rhis Counry ro eMer�pon the
above-mentioned prapeny for inspaction purposes. SEE REVERSE POR EXPLANATORY LANGUAGE
L��i�-�
n y y Permitfe� Date �
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_��_. ,__,_�„� !� � .. . - ' � for th� �lieyzd h c..pUen. l,ny viofat'nn o $act�aix
(� c� __�._ ._.._'..___'_ .....__.. . __....._._�__..._._._._...T.-._.__ 7031.5 by r.r�y opy��-^nt{�� p s� � �_ pp'i
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�- .� . . . - . tar's t(eunse Cev✓dae<aot npvJy to ac owner af p'o-r�rty
� . w6o S�utfds ar imnroves tncrca«, and whn does such
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work F,'rmscf�provlc�ad lhcP suc?a impravemcnrs are nat
� . Intono�d or 4#iered for sota.If,hn�ever,ihar 6aildlr.g c!
_ . ' -, �'� '.;, —. _ ._____�_._.._....�.__"_ _ In�prcvemc�-�t is scld w'riiiin one year of c i..;+ron, t};=,
pvmer-Ge.d7der w711 hovo}h�+6urr?er.af proving tfsai he d id
� _�y� ...�� � - nnt bWtw cr imprave fnr thz pvrFos�r of sQ'a.l
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