HomeMy WebLinkAbout1454A WORRERS'COMPENSATION OECLARATION APPLICATION FOR PLUMBING PERMII' �
, I,hereby atflrm ihat 1 have p certiflcote of mnsenr fo sel{ 76A667A
nsure,or a certificofe af Workeri Compensafion Insurance, CE 817(REV.IOiel)
o�o c�+ f� copy Iher�f�,5ec 3800,lab.C.) COUNTY OP LOS ANGELES BUIIDING AND SAFET
� I�' j��s��
� O�Y� � �CompanyaL� ` �� ��6 �i,
CerYified copy is hereby f�mished. �
FQR APPLICANT TO FILL IN(PRINT Oft TVPE) BUILDING 1A /�t'�'� �
�Certified copy is filed with fhe county building inspec- ADDRESS !�� �!V
Do�e�tion deparf e NUMBER FIXTURE OR ITEM @ FEE ��AIITY ��-�
Appli4anf y � ATEkCLOSET "V' NEARE57
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB � CRO55 57.
COMPENSATION INSURANCE OwNER � �
(ihls soction nwd not be complated lf iha work involved by SHOweR '
ehe �rmk is for one hundr�d dollars f100 0!I�fi. Mp'��
P I ) J LAVATORY � E�'`y AODRES$ . .
I certify thot in the performance of the work for which this
permit is issued,I sholl nof employ any person in any manner SINK a.r CITY T -.
so as to become subjeci ro�he Workers'Compensotion Laws. DiSMWnSHER /"
�'�' CONTRACTOR �� �
Dofe Applicant CLOTHES WASHER ADDRE55 Q~/ �f�
.��*+nTICE i0 APPLICANT: If, after making this Certificate of - � v�l i �/" �
� mption, you shou�d 6ecome subject to fhe Workers' SWIMMWGPOOLRECEPTOR
wmpensation provisions of ihe labor Code,you must forth- Ciiv � T . �yqq
wifh comply wilh such provisions or ihis permit shpll be �AWNSPRMKLERSYSTEM STATE ^7 /T LIC. (
deemed revoked. � WATER HEATER LICENSE NO. .7 IJ 0 CLASS fC
LICENSED CONiRACTORS DECIARATION Di57RicT NO� aROCE55e0 BY
I hareby affirm tho!I am licensed under provisions of Chapter 9 GAS SYSTEM OUTlETS �
(commencing with Sec�ion 7000)of Division 3 of the Business OUi�Ei50VER
� and Professions Code,annd my license is in full force and effect 5 aER SVSTEM FINAI V IDATION
Litense Num6er �v� � Lic Closs � �� DA7E ?'�14/� p�
cJCM '^(��� FINAL �r�+� U.
Contrador Date�� BY //G• at a.
� O
I am axempt undar Sec U
B.BP.C,tor th�s reason � W
Plan check fee Q.
� D��e� PLUMBING PERMIT 15SUING FEE$ (`� �
$ignafure '
TOTAL FEE ;,� �.�5.U�A
Plan check applican� .��A
SINGLE FAMILY a ° • ' •.r7
HOME OWNfR-BUILDER DECIARATION Name I ° ^7 C,J�O
�^re6y offirm that I om eaempt from ihe CoNrador's License Address
s for the following reason(Sac�ion 7031.5, Business ond ' �- _
Professlons Code): Ciry Tel.No. m " `�j�,`��
❑ I,as owner of fhe property,will do�he work and�ha Q Q� �—g']
� sliucture is not iMended or offered fof sole (Section �
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby aHirm�hol�here is a construction lending agency for
�he performance of�he wo�k for which this permit is issued
(Sec 3047,Civ.C.).
tm�d8c'pl�alne — --
Lendee's�4'dtBm— --
I cerrify�ha�I have read this applimtion and state�hot the �
obove information is correct I agree to comply with all Counry
ordino s ond 57ate lows regulating Plumbinq,ond hereby
ou�hori e ep anta�ive of Ihis Covniy to enler upon ihe '
o6ove- e tio for i pection purposes.
� SEE REVERSE FOR EXPLANATORY LANGUAGE
�
S� ure of Permittee � Da�e
_,..�-. ,__ _,_.._ ____ - - ----- -- ------ �.,
�►�i��• �i+4��'� . ' �f � MI';;' �_� 1�4A
iNSPECTOR'S N07E5 ONiNE2-BUiIDER DKIAR.ATtON�
�._4�'w �_W.� CALF !hS?E R'S �GNATURE . _ . .
UN7 A�i 7 I I here6y aff`-m ihal I am ero p(P-om ih- C . �1'?r'�
EOUCiPC�� 1 �—�� , " Ccense Low 4or the folloWng eason (S�ct G3I.5.
-�-`-- " - -- Bus ness and Pro�assions Cod=�J:Any nly or o nty w fch
.,AS P P�� _ _�'� _ _. - � requires a permit fo canstruc},alfer,improve,d�molish,
'GAS VEr,T �_ � -or ropdir cny struEfure, prror io its issu
an�e, nlso re-
407 bVniflF W 'C�.° � � - quires the applicant for such permif fo file a signed str.te-
�—__'..'_
y ptUM61tiC��F��.�^�.!i;�5 �.. . ' ' menl lhcf he Is llcansed pursuont to tlie provisions oi�h�
------ � � Conlractor's Licartse Law(Chapter 9(commencing vrith
�vA5 T;`T i�,. . .
�U71-ITY��.P I� � � Settion 7000)of�ivision 3 of fhe Buslness and Profes-
_��.
._�_ ____..l __� —_—.� �. • � sions Code)or fhot fie�s exempt therefrom and the bosis
I
__. _-�7 __ ior the olleged exc•nptfon. Any violalion oi Secfion
p;n�q�' .. ' lf;.frr n -tronl ' - � � . ' 703i.5 6y any opp7iconi lor o permit subjects the eppli�
— ___._.—
cont to a civJ penalty of not more ihan five hund`ad
� �� � • doilorrs(S500J:
n,�i r���r�_ ^ � � � � . � ❑I,as owner of 1he property will do�he work,ond
V�k ri': � � the slruciure is not intended or offered for sale. —
i....��...._.._...__.._,._�.._�._.
� . � (Ssc.7SIM,Burinsss orrd Profe�siorts Code, 7he Cc .
� � ' � ' , . ' for's License Law don nof apply fo an owner of properfy
� � � . - wbo buflds or lmproves thereon, and who does such
. , wwk himseff provtded tho�such improvemsnfs ore not
interEded or ofiered fo�sale.If,howevcr,The building or
� - improvement ls sofd within one y�ar ol completion,fFe
��, owner•bulfdar will have Ihe burden of proving�hat he did
`—^' �� � not build or improve ior}he pwposq of sale.j �
I am e�aemp'under Sec. ,
;
� � B 8 P.C.for this reason �
-�
Dafe
Owner
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; .'S"'�Ci�R'S NbTES