HomeMy WebLinkAbout1193 . I Nereby affirm tNat I hove o certificoie of conseni ro self �yqyb�q
APPLICATION FOR PLUMBING PERMIT �
insure,or o certificafe of Workers'Compensa�ion Insuronce, CE 6I7(REV.10.�81) �
, or a cert�fied mpy iMereof(Sec.3800,La6.C.) COUNTY QF LQ5 ANGELES BUILDiNG AND SAFETY
� P�ollty No. Compony
Certified copy is hereby furnished_
❑ � FOR APPLICANi 70 FItL M(PRINT OR iYPEj BUIIDING q)�3� fif' p rS S
Certifled capy Is filed with the couny 6uilding inspx- ADDRESS d-J �• L'l .Z`�
, tion deportmenf. NUMBER FI%TURE OR ILEM r(� FEE Q h f�
40CAlITY l'I/��/�O N/-+ . +`
Date Appli4nnt wA7ERCtoSfT
i NEAREST
CERTIFICATE OF FXEMPTION FROM WORKERS' BAtH 7UB CROSS 5T. L � /�y �, �(�.(�
� COMPENSATION INSURkhKE � OWNER � `L5�, //UFFL�/l.
(TNis�eNion�n�d rrot ba eompiaf�d It Ih�work lnvolwd by SHOWER
� tM1� •rmit b tor ona huedr�d dollan StOQ or la». MAIL
p ( ) ) invnroRr ADORESS J�?G
I cenify that in�he performance of the work for which Ihis .
� permit is issued,I shail nol employ any person in any manner S�NK CI7Y TEL.NO �'�'�;Q
5o as to be[ome 5ubjetllo ihe W kers'Compensotion Laws. �ISHWASHER
�9�..3r ���N'''. 1 coNrRncroe p u.J�V�R _.__.—.'�
Doie pplica CLO7HE5 WASHER /"'
NOTICE TO APPLICANT: If, ofter making rhis Certif" of ADORf55
Exemption, you should bacort�e subject to the kers' SWIMMINGCOOLRECEPiOR
1 Compensation provisions of Ihe Labor Code,you m�st 4orih- pTY TEL NO.
�� wilh camply wifh sucM provisian5 or fhis pevmif shall be 4AWNSPRINKIERSVSTEM STATE UC.
. deemedrevoked. WAiERHEAIER UCENSE CLASS
� IiCENSfD CONTRACTORS DECIARATION DISiRICi NO. a�iOc�55ED BV
�, 1 hereby aHirm tha�I am licensed�nder provisions of Chap�er 9 GAS SvSTena OuitEiS ��1
�[ommencing with Seciion 7000)oF Oivision 3 of the 8usiness OUTLEiSOVER v
, and Professions Cade,and my licen:e is in fuU force aad effxt. 5 aee SVStenn F�NA� �'
oqre C i vA�� AT10N �
�� License Number Lic.Class 6�"y/f V
fINAL ar
' Cantwctor Date BY � /�9 3 n
�
� �+ W
1 am exempf under Sec. `7 �
. 6.8P.C.for this reoson �F
Plan check fee �
Dore: /�•�v
C . PLUMBING PERMIT ISSUING fEE$ (�l ��
' Signafure �
� TOTALFEE � � �] �i
' Pian check applicant '—�+ � J"9'O �
SINGLE FAMILY
Y HOME OWNER-BUILDER DEQARATION Name �. �.—' �J���j ' � .
� I hereby otfirm�hat I nm exempt fram ihe Contrador's license ,�-�
k low for the following reason(Setlion 7031.5,Business and Address ��I �� /39� [J,rj t��G S
p �ssions Code): . City ��p Tel.N �ti- �j�
t
( I,as owner of the properry,will do the work and the �
� strocNre is not intended or afierad for sale(Secrion �
4 7044,Business ond Proiesaions Codqe).
' CONSTRUQION IENDING AGFNCY
I here6y affirm thot rhere i:o mnstruc�ion lending agency for
the performance af fhe work for which this psrmit is iswed
�� ISec.309I,Civ.G}. ,
� Y9R�mCY0�7.r�l�
�. Lendm's a�-- .
i I certily�hof 1 hava read ihis application pnd stofe�hol�lha ►
obove informatio�is twrect.I acyae to tomply witM pll Counfy
' ordinonces and Sloia lows regulating Plpm6ing,and he�eby
. authorize representotives of this Coumy to enter upon the
obove-menrioned prop rfy for insp�c�ion purpo es.
7 � �� ��f�� /� SEE REVERSE FOR EXPtANATORY LANGUAGB
-�.,�-' -- -- -
� Signature af Perminee � - -
t���
AVPRCVALS oa� ir�ecEtOa55�oraAauRE IW6FfCTOR'SNOTES OWI�R-BiJll �
UNDERSIAe WORK I hereby affirm that I pm exempt from the Conlrac�o!s
ROUGHP:UM&ING � License Law for the followin� r . n (Se�ction 7031.5,
GAS PIPING � Busfrtess and Professions CodsJ:Any cfty or caunty whrch
GAS V€M requlras a parmit to conssrud,alfer,improve,demo�ish,.
r ropalr any sfruc}ure,prior to its Issupnce, also ro
HOT N45TER HEATER qu(rse f(+�applicant for s�eh permff to filE a slgned stote-
MUMBiNG FlXTURES ment�hat he is ficensed pursuant fo the provisions of�he
GRS TE§7 , Contractor's Cfcenso tow(Chupler 9(rommencing wilh
UTItITY CO.�OiIFlc'D SeMion 7000J of Dlvision 3 of fhe Business ond GralFs-
sio»s Code)or fhat he Is ezam�t the:efrom and the basis
c� ior fhe allegod exemption. Any violatio� of Section
FINA� �x.fpr on Jronf . 7031.5 by any applf¢onf(o.-o permit wbjacts ihe oppli-
� corrf ie o clvil pencky of nof more Ihan fiva hundred
dolfars($50B).:
iNOUSiRIAt � ❑I,as own�r cf the property will da the work,and
WASTE APP�COVAL the strumture Is not intended or offered for sale.
� (Sx.7W4,8ustfross andPrafessians Cade: ihe Conlrar
ior'e Lle�nss Low Jws m.T opply lo 00 owrter o1 properfy
� who bWlds or impro�es fMrson, and who does su<h
wark h(mseff provld�d fhat such improvsmonts are nof
Intended or offxed for sale.N,hmwevx,ffie building or
Improvamint Is aofd wlthln artv year of completion,Ihe
- � owtmr•bulfder wil!have 1he burden of proving fhat he did
. � nof bulfd or irnprove fcr tYie purpose of sa(e.)
� � � I am exempt under Sec. .
� B 8 P.C.for ihis reasan
Date _
Owner
INSi+ECTOR'S hfOTES