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Home My WebLink About1364A � WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PtUMBING PERMIT , I haraby affirm that I have a ce�tificate of consent to self �gq��q � � insure,or a certificate of Workers'Compensa��on Insuronce, CE 817�RFV.10/87� �� or a cerlified mpy Ihereof(Sec.3800,lob.C.) COGNTY OF LOS ANGElES BUILDING AND SAFETY oEy�. Compony Certified copy is hereby furnished, � FOR APPLICANT TO FILI W�PR{NT OR TVPE) BUILDING '�� y y A �� Cer�ified copy is filed with ihe county 6uilding inspac- ADORESS /�r� hon deportment NUMBER fIXTURE OR ITEM- @ FEE p��rno�D � � t LOCAUTY ' Date�`�� Applicant. WAffRCLOSEf � NEAREST 1� CRO55 ST, R—L0119�Q S� KI.B � CERTIFICATE OF EXEhhPTION OM WORKERS' eATH TUB i ! COMP€NSATION iNSURRNCE SHOWER owNeR � � � (This s�ction need nof bs compVNtd iF fha wark invo{v�d 6y MAI� r7 � tbe permif iY for ona huedrod dollan(5100)or(ess.) tqvaiORv ADDRE55 � ` Z.. Q � 1 certity that in ihe performance of fhe work for which this pe+mit is issued,I sholl not employ any person in any manner ( SINK pr4 CIN 9�.�,�� TEI.N0. �r� i so as to 6ecome subject lo�he Workers'Compensation Laws. DISHWASHER- � /'�_��, C�J CONTRACTOR G `�� Dpte opplicont CLOiHE5WA5HER ADDRESS r—�{-� NOTICE TO RPPLICANT: If, aker making Ihis Ca*tifimfe of � 6 uv �t'�,.� � Exempiion, you should become subiect to Ihe Workers' SWIMMINGPOOLRECEPTOR � Compensation provisions of the Labor Code,you must forih- CITY .nr��,�. TEL.NO.��,a�„ with com I with such ovisions or this rmit sholl be �AWNSPRINKIERSY57EM P Y W PB STATE LIC. $��) - deemed revokad. WATER HEATER LICENSE NO. u�a �0 LLA55 �J � LICENSED CONTRACTORS DECLARATION � / � DISTRICT NO.� PROCESSED BV � I herehy affirm that I om licensed undar provisions of Chapfer 9 � GAS SVSTEM OUTLETS � J . (commaocing wiih Section 700E3)of D�vision 3 of the Business Oui�eiSOvea 6 . and Professions Code,and my license is in full fwce and effect. � 5 P[R SVSienn � �' �ATE��°" VAL ATION Q license N�mbar��`�0 lic,Class� � ��n V .�� FINAL .� � � � ' Comrador Q�i Date��_� BY ��;�� _�x",;,," d ❑ I am exempt under Sec. un G. �a ; . B.&P.C.for this reoson Plan check fee . � � �ate: � - PLUMBING PERMIT ISSUING FEE$ lU Signature � TOTA�FEE �O �i� 3(�4 A � Plan check applicant #'• • �.u •u � SINGLE FAMILY � HOME OWNER-BUILD€R DECLARATION Name I ° •2 4,O O � I hereby affirm thor I am exempt from the CoMrocfor's License � , Law far the following�eason (Section 7031.5, B�siness and Address . _ � Professions Code): e ` `'<<��U�� . ❑ City Tel.No. I,as owner of the property,will do the work and�he . Q 7,� E-S 5 siruc�ure is nof intended or offered for sale (Section � � 7044,Business pnd Professions Code). �, CONSTRUC710N LEN�ING kG@NCY � I hereby offirm thot�here is a construction lending aqency for � ihe performonce of�he work for which this permit is issued (SeE.3f}97,Ciw.C.). LTfnl�SYS WCTR � kCrRfEr'a R�s I cartify thot I have reod this opplication and state that the � above inforination is correcL I agree ro wmply wi�h oll County , ordinances and State lows requla:ing Plumbing,ond hareby , aulhorize repraseNotives of this County to enler upon the ove-menlioned proparty for inspection pu�posea. SEE REV8R5E FOR EXPtpNATOkY LANGWAGE �� ,�.� �—�� ' Signature of Perr� Date � napROVALs �Aie w5P€C70R'S SiGNATURE ' �p��$�� OWN€R-BUILDER D€CLARC,TION UNDER SL4B WORK � I ha�reby affirm inat I am exempt from the Contractor's ROUGH PIUMBING License Law for ihe following reason (Sec�ion 7031.5, GAS PIPMG - B�siness and Prolerlons Code):✓iny cfty or counfy which GAS VlN7 reyalras a permif fo construct,oNsr,improve,demolish, HOT WATER HEATER ' or repalr ony sfructvre, prlor to it, Issuance, also re- . quirec ih�appdicani for such pe:mi�to file a sig.h�d siate- PlUh�17J6 FlXiURES mont fhol he!s lic�r+sed pursuar+f la�ks prcvisions of�he GAS TEST Confra[for's Litense La:v(Chr�ler 9/commencing wilh UTILITYCO.NOTIFlED $ection 7000)of Divisior.3 of lhe Busir,ess ond Profes- sions Coda)or th�t ha!s exempt thw'errom and ths basis c'y 1or fhs alJeg�d exempNon. Any violaticn of Soclian FINAL �nfa*on _tranl � 703(.5 by any applicant for a permit suEj�tfs the appli- cnnt fo a ttv!(penalfy of not more Ihan Iiva hundred do++o�:{s5oo).: iN0u5iRIA� ❑I,as owner of the prope;ty wil�do ihe work,and WAS7E APPROVAL � }he Sf�ucdure is not infended ar offered for salo. � (S�¢.7(141,Bvsiness and Professions Code: The Controc � . tor e Lls�n»!aw dt»s not opply 10 an owner of property wha bu7lds or Improvss �(»reon, and who does such . work hfmse7f provldad Yhaf such improvernents wa not lnlendsd or offerad fer sals.1!,however,tha bullding or � � lmfgnremsnt ia sofd withln one yeor of complefion,fhe owner•build�r wil(hav�thr burd�n o?praving tFaf ho-did nef build or Improw for fh�purpas�of sals.) I am exempt undsr Sec. , B 8 P.C.for ihia reasan Date Owne; I!V"sf+GCTdR>5 NOF�Si