HomeMy WebLinkAbout0872A � � �'�"nrr _�"� ��.� � �Ya.ay � �_ _ _ � � �" • .. if
WORKERS'COMPENSATION DECLARATION J6M6]A C'
1 hereby affirm that � ha�e a certificate of�o�s�t�o se,f �e.,,�A-so, �A P P L 1 G A T t O N FO R P LU M B 1 N G PE R M IT
insure,or a certificate of Workers'Compensation Insurance,or �J
a certified copy theraof(Sec.3800,Lab.C.)
�/������� +�. COUNTY OF I.OS ANGELES BUILDING AND SAFETY
Policy No. Company�?-A���'�'�� � ,,
� � Certified copY is hereby furnished. FOH APPLICANT TO FILL IN(PRINT OR TYPE) qp�DRESS � ��p
� Certified copy is filed with the county 6uilding inspection NUMBER FIXTUFE OR ITEM � FEE
AePartment. IOCALITY
WATER CLOSET
Date ADPlicant NEAREST (1 (1 � �
BATH TUB CROSS ST. �...CYt i
� CERTIFICA'IE OP EXEMPTION FROM WOftKERS' .
COMPENSATION[NSURANCE . SHOWEF OWNER
LAVATORY MAIL
(This section need not be completed if the work involved � aoDReSs }
by the permit is foi one hundred dollus (5100)ox I056.� SiNK
CITV ��l TEL.N�� �` O
� I certify that in the performance of the work for which tMs DISHWASHEti V
permit is issued,I shall not emplov any person in any mannex CONTRqCTOR �,Q
so as to become subject to the Workers'Compensation Laws, CLOTHES WASHER + , �
AOOR ESS��'" 0
Date Applicant SWIMMING POOI.FECEPTOR � ~
� NOTICE TO APYLICANT:If,after making this Certificate of � CI7Y TEI.N0.9�`� W
Exem tion, you shauld become subject ro the Workers' LAWN SPRINKLER SVSTEM ,
D STATE 1 LI4 (A
-�Compensation ptovisions of the Labor Code,you must forth- LtCENSE NO.d- � CLASS `J Z
Nith comply with such provisions or this permi[ shall be WATER HEATER —
� �eemedrevoked. GASSVSTEM OUTLETS l�, O� DISTRICTN0.� �PRhOCESSEDBY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER �� � ' ��L�CJ�`_Si.
�hereby affirm that I am licensed under provisions of Chapter 5 PE R SYSTEM , . � , �
i (commencing with Section 7000)ot Division 3 of the Busi- L� FINAL � ,VALIOATIflIV
pess and Professio�Code,and my license is in full foece and �S `� ��'�-�' � DATE J��.�-�'�.. -
�ffect. � � . .
�, FIN L
,��License Number���Lr�iIa Class C��� \ BY
�Contractoj'����eL�/���3at� /���
� � I am exempt from the licensing requirements as I am a Plan Check fee . .
licensed architect or a reg�stered profeasional engSneer pLUM81NG PERMIT ISSUING FEE$ �d - �
acting in my professional capacity (Section 7051, Bus- `J
iness and Rofessions Code). TOTAL PEE aQ rj('j - �
Lic,or Reg.No. �ate Plan chack applicant .
HOME OWNER-BUILDER DECLARATION Name .
I hereby affirm that 1 am exempt from the Contrector's Addre�s � � -
License Law for the following reason (Section.7031.5,Husi- City � Tal.No. � .
ness and Professions Code): �
� 1,as owner of the property,am exclusively contracting � � � ��
with licensed contrectocs to construct the P�o�e�i � .�0&7,2 P -
� (Section 7044,Business and Professicins Code). �
�!• • . •J
CONSTRUC7'[ON LENDING AGENCY �
I hereby affirm that there is a consttuction lending agency � .� a m`�(?5('j
for the performence of the work for which this permit is .
issued(9ee.3097,Cjv.C J. � . •a .��i�,i��;
hartdn's Per[re
17_.G�-8,1
LeiMeYg A�detens�
[certiFy that I have read Ihis ap0��ca[ion and state tnat the
above information is correct.I agree to comply with all County SF.E REVERSF.FOR F.XPLANATORY LANGUAGE .
ordinances and State laws regulating Ylumbing, and hereby
authorize representntives of this County to enter upon the ,
abo�v {''entioned property for inspecNon purposes, �
�"(�nc ��' /�i bt•�ra�r.../� //-3v-�/
� �'nature of Parmittee Date
�, _ ._ , __ — —.
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IPdSPECTOR'�^:OTE� •. .. •-f�..�1:E�..�3�*'.:L1�f.i�i:�id
APPFOVALS DATE IN9PEC"fOR3SIGfVATURE _�. .�.__.� .___.,... .__..,,_.....__..._,».._... "..-.
UNGEF SLAB WORK � �
ROUGH PLUMBING ---..._�,__.�._._e._.�_ '.L�r.�h.c�.. ,.�m t:�;:f a-,�.:r�rinpt fron�thu(:ontr,clo:�s
�i=^ 1 f-.: tl� f ��r �n•. r .`��-(S+'ctinn 7031.5,
GASPIPING a. _�..�_ e __'__."_'_'_'_"_'_� L :'.is r':i:�. ('o:;� ,r.;r cit)� or Co�tnlV.
GASVENT . 1�'(:t:''; f:�'[^�:i': G'�(":';'i::i� fo�CG!!.;tlztCt. Ultc'Y. i�;:pYOt�e.
. —_— _..^, d��,.r:'i.';.nr r.:;�-'r r..,.p si.�rcture',Gri:�r!a its is;��ar;ce, -
HOT WATER HEATER I � ------------�-----
'LVF1MhY6 PYNTI�RB � -- - G . 1'_.,• f;.,.. c �.ra^t for Scc7: perrr�it ta fife Q
.�.—._._._�_._ . �, r . ..� �!. . f��r i.s Pceasrr' prrrsuant tn the .
. �ASTEST .,� .Q/,U,.�_ . r ._..__ c` �', C� �U"�•ror'v Lice�tsr I.¢«'(Ch.7pter 9
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INSYECTOR'3 NOTES