HomeMy WebLinkAbout0895A WORKERS'COMPENSATION�ECIARATION APPLICATIQ[V FOR PLUMBfNG �'
�I hereby affirm �hat I hcsve o certificate of consant�o self �b,q��q ���1 /'
insure,or o cerfifiwie oF Workars'Compensafion Insuwnca, CE 817(REV.1Q/81� �7�
or a certifiad copy thereof(Sec 3800,Lab.C.} COUNTY OF l05 ANGELES BUILDING AND SAFETY �
• O�Y NdaP 3213�,Ppny Fremant Indemnity ,�3
Certified copy is he�eby fumished.
� fOR A7PlICAN7 TO Fltl IN(PRINi OR TVPE) BUILDING
Cartified topy is filed with the county huilding inspec- ADDRESS, � S � �_�
�ion departmeN. . NUMBER FIxTl1RE OR ITEM r@ FEE _
LOCAUTV
Date h f 7�I�SAPPlicant • WATER CLOSET
CERTIFICATE OF EXEMPTION FROM WQRKERS' BATH 7Ue
` CROS5557.�D . ��
COMPENSATIOPI INSURANCE SHOWCR � ~ OWNER � �u��� ��-�
(This seetimi nwd noe b.oomplof�d if tM wprk Involv�d by �7 MAIL
th�permit fa fer cM hundred delbrs({700)or lu�.) � LqVA70RY �p� ! ADDRE55
I certify that in the performqnte of the work for which ihis � _�
permit is iswed,�shqll noi employ any person in any manner SINK CITY TEL.NO.
so as 5a become subjecl to the Workers Compensotion Laws. / DISHWASHER �y � CON7RACTOR
Dale Applicant CLOTHES WASHER � � ADDRESS U
.'"""ICE TO APPLICANT: If, nfter making this Cenificate of �o�- �� �
npiion, you should become subjecY to fhe Wo�kers' SWIM7dINGPOOIRECEPTOR
Compensation provisions of the Labor Code,you mus�forfh- CRY .I G TEt.NO3���Q�j D
LAWN SPftINKLER SVSTEM V K
wiih comply wifh such provisions or this permit sholl be STaTE LIC. /�
deemed/evoked. VIATER HEATER s / � IICENSE NO. . C1A55 C�
LICENSED CONTRACTORS DECIARATION � pISTRICT NO. ROCESSED BY
I hxaby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTlETS I�
{commencing wifh Section 7000)of Division 3 of ihe Business OU7lETSOVER
and Profassions Code,and m licenge is in tull 4orce ond effect. 5 PER Sv57EM ' '�
Y
- DA E� �� ti��'S vnu4nnoN n
License Number ��—�-�g�_Lic.Class�_ V
R.C.R. Pluaibi�g E>�.ZZ�SS BYAL y� �
co�o-anor 2� Qr
❑ u
1 am ezempt under Sec �
�
B.&P.C.for this reoson Plan check fee � _
Dote:
PLUMBWG PERMIT ISSUING FEE S n S(�,
Signoture
TOTALfEE , (
Plan che<k opplicaM
SINGIE FAMIIY -
� HOME OWNER-BUIIDER DECLARATION Name �e.�. �. l (�, ,"0&9.5 A
eby affirm Ihat I am exempt from�he Coniracbr's Litense Address
L..w tor rhe followinq raoson�SeU�on 7031.5, Business and � $��• • • . .5
❑Professions Code�: . �City � T Tel.No. —.U'aO d I • •&�.v O
I,as owner of the property,will do the work ond the �
strudure is not inrended or offered for sale (Section ► �,o � r z
7044,Business ond Professions Code). � .
�� ..Qc±
CONSTRUCTION LENDING AGENCV O 6.�� "�S
I here6y affirm Ihoi there is a conshuction(ending ac}ency for
the parformonce of the work for which ihis permit is issued
(l.�.�',Cio 8.)�
Lendmr's Nome
Lender's Address
I ceriify rhoi I have reod this applicalion and stole ihot Ihe .
above information is correct.I agree ro comply wi�h oll Coun�y
ordinances and Stofe�aws regulating Plum6ing,und hareby
authorize re+xasentatives of this CounYy to enter�pon the
abov +�oned pr erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
R.G�.E�. BY ' / /) p� 6/21/85
Cu�
Signature of Permiltee Dafe
��
.4rpRDVklS DAiE IN 'SS�GNATURE INSPECTOR'S NOTES OWMrR-EUILL'cR UECLARAIID\I
UNDERSLABWOR� �,���(�' I hereby affirm rhat I o .-�p1(rom tF�a Conrmcbr's
ROUGHPLUMDMG License Law for the foilo�winy reason (S.aclion 703I.5.
GAS PIPMG 6us/ress orrd Profcssions Ccdc):Any city or rounty which
GAS VEN7 requires o pnrmil ro cons�ruc�,vlPe,r.irnprove,nemoli;h,
�'�r or repoir any st�uc9ure, prior lo its is;uancc, also re-
HOi VIATER HEATER quires ihe eppl7cenl 1or sucfi perrnit}o file a signed stoie-
PLUMBM;G FIXTURES � menf fhal he is licensed pursuanl to the provlsions of Ihe
GASTEST ,2g Confrador's License Law(Chc��er 9(commenNng with
�nIITY CO.NOTIFlED Secfton 700Fij of Division 3 of ihe 8usiness cnd Pro(es-
sidte Codx)or fhot hv is exe�w�t 1l�erefrom and tne bosis
r !or fhe olfegrd exempfion. Any violcfion o1 Secfion
FWAi [nter u �nf 7031,5 by ony opplicant(o�o permlt su6jAcfs fhe cppli-
. .. cant lo a civi7 pcnalty of not more f,4on five hundred
� dolfars($500).:
INDUSTRVAL ❑I,as owner of fhe prope:ty will do the work,and
VIASTE APPROVAL � tha struduro is not inlended or offerod for scle. '
(Sec.70M,9usiness and Professians Code: The C ao
� � tor's Ltcense Law doee no!op�ly�o an owner oi property
who bullds or Impravss ffierean, and w!w�lues such
- work hhor9elf provide�fhnt suth lm�rovemenis are nof
' intertded or offered for scla.If,hox•rver,1ne 6uUding or
� , Improvernen�Is sold within onc year of complelion,�he
� awner-buildsr wilf have tfie burden of proving thot he did
no/bulld or improvc iar the purposv af safe.!
l am exempt under$ec. ,
B&P.C.for this reason
Date
Owner
IN6P6�TOR'S NOiES