HomeMy WebLinkAbout1835A �� W 'CqMPfNSA710ND€CLARATIOW APPLICATION FOR PLUMBING PERMIT �
I here6y affirm fho� I hove a cenifimie of consen�to self �yqyy�q
,insure,or o certificofe of Warkers'Compensdfion Insurance, CE BV(REV.10/BI)
or a certif�iad��c[o/pe�y Gt�hGa]reQof��{Se'jc.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING ANDSAFETY
P❑olicY No�'��GoYr�¢any ��� �� '� � � 1
Cenified copy is hereby fornlshed. - ,
� fpR APPLIGANi TO FILL IN(PRINT OR TYPf� BUIIDING
Cerlified topy is filed with the counry 6oilding inspec- n�DRE55 {'►Yl i S
tion depa 1men�. NUMBER FIX7URE OR I7EM @ fEE �OCAIITV
Date� °1-Il�€��.APPlicanl���y��� WA7EFCLOSEI � NEAREST �1A�0�'1�,J� (.LY'
.CERTIFICAiE OF EXEMPTION FROM WORKERS' � BATH T1/6 � CRO55 57,�ICiS OI'ZCrI Y �1
COMPENSATION INSURANCE owrvEe �
$HOWER
(This s�clfon n��d not b�compl�fod if th�work lnrolwd by ���
1h�p�rmif i�for on�hundr�d dolfon(5100)or I���.) �a.vnTORv ADDRE55
I cerlity tho�in Ihe performonce of the work for which this
permit is issued,I shall no�employ ony person in any mpnner 1 S�NK QTv �dv��� TEL NO. 67�9�I
. so as 10 became su6ject fo the Workers'Compensotion Lows. DISHWASHER �c 1°
I y� CONTRACTOR �' �Y. ��
� Date Applicont CLOTHES WASHER r
,r'nTICE 70 APPLICANT� If, affer making Ihis Cenifica�e of AO�RE55 ' Q , S�'�- h Cj V�,
SWIMMING POOI RECEPTOR
' nption, you should 6ecome subject lo Ihe Workars' ,�,[�^.y� �
�ompensolion provisions of the Labor Code,yau must for�h- LqWN57RINKlER5Y5TEM ��T"'-'�� 1� V� ' '��
with comply with such provisions or ihis perml� sholl ba STA7E r� �ry �IC. /1
deemed revoked. . ' WAtER HEATER �.� LiCENSE NO. '] �i D . CLASS �+
LICENSED CONiRACTORS�ECIARATION �iSiRiCt NO. aROCESSED BV
I hareby offirm that I om licenaed undor provisions of Chapter 9 ' GAS SVSiEM OUTLE7S 8� i h �- .
l 4/
(commencing wilh Section 7000)of�ivision 3 of ihe Business Ou7tEt50VeR
iand Professions Code,and my licanse is in full forc^Je and a0 act. 5 PER SYStEM OATEL L�/�/b O VAIIpAT10N y;
License Number 3�3��3 Lic.Class�-' ���� LL
� _I t f � FINAL U.
Contmctar 1 C•n Date -� y� BY ��� �
I ❑ I am ezempt under Sec. U
' B.BP.C.far this reason `�' F
Plan check fee . ' � `'``' A nW.
�ate: pLUMBING PERMIT ISSUING FEE S {��° ° ° @� `� Z
Signoture —'
T07AL FEE � " `� �fi�L)
Plan check applicant �, - %t,.�,1.�,�
SINGLE FAMIIY
� HOME OWNER-BUILDER DECLARATION Name 7i C?� %-�,J
� reby affirm thm I am exempt from the Contrac�or's License qddrass
_ ,�for the following reason(Section 70.31.5, Business and
Professions Code): C��y Tel.No.
❑ I,os owner of the property,will do the work and rhe
� itructure is nol iMended or offered for sale (Section �
7044,Business and Professio�s Code), �
CONSTRUCTION LENDING AGENCV .
1 hereby affirm tRat ihere is o construdion lending agency for
the perfwmonce of the work for which this parmi�is issued
(Sec.3097.Civ.C.�.
kerrt�r'�Nmnw - .
LaE+d�er'a A�ttt}Feaa -
1 ceriify�hat I hove read ihis opplim�ion ond state thot the ►
above informplion is mrrect.I ag�ee Io comply with oll County
ordinonres ond S�a�e laws regulating Plumb��g,ond hereby
au�horize represeMo�ives of this Counly �o enter opon rhe
above-mentioned proprrty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
���=�-�-`�-�-�-
S naN e of Per ttee Date
�� �' r �
� , ��'��•�•.
'�r"'�r►s •.e +� �
'!- _� .�� - �+����+r�+�.s.!i
nPakovr!5�� A7E iNS�E R'SSiGN�TURE INSPECTOR'SNOTES , OV�/NEP.-BUILDERDECI.ARAiION
JN�ER 5LA6� b �� �, . � ,~ �. � ' I hereby affirm Ihat I om exempt from fnc Co t. ior',
ROUGHFW4 I - Ccense Law for tF. follo ieg son (Se.t.on 70J1.5,
GAS P PIUG� __ ;���^ �i � � dusiness vr.d Pro/esslons Code):Any clty or cour fy wh-r.h
�—�----- — � requirezopermilfoconsVucl,alter,�mprove,d�malish,
GASVEN' ' � _ � � -
NOT V��A7Ex F��L.�7t:r or'repair any structure, prior fo ifs issuance, also re-
_ �_ �� � -quires the ap�lfcant lor such permir to/rle o signod zmre-
PL�h+CING:i::-i!�'S I � '� � - � � � ' � ont thet he is liconsedpursuan'ro fhe provrsiqrrs oi the
""�"'-""""'—` Conlrocfor's!i[ense Law Chn 4er 9 mmmencing���i'h
GASTESt _�.—___._ _'__�' I .____ — —_�� � � �
UTILITY CO.NO?F',�D � Section 70001 of Division 3 o/the Business and Proles-
--- — . - sions Code)cr ihof he Is exemp��herefrom artd�he basis
_ ___..��_. ,_. __ I ._..__� � �' � for fhe olleged ezwnplioa Flny violation or Section
p'�nq� ' . ,.�f . . � . --'-, � - 703L5 by on�apPlicanf for a permit su6jects the oppli-
:',e(rr o�c �ronl � � cont lo a tivil panal4y nl not more fhon live hundred
...--_..__. .
___._
. ' _ �� ! ' ��-,� � � � � " doffars(5500).:
wDuSTe'�ni � , � � ❑I,os owner ot the proFerty w�ll do ihc work,�nd
�"•'Asie:F'a0�'^,- . �_. �.. _ � � � - —`"`"""" "'—"� the ssructure is not intended or offered for sole. --.,
� � -� � �� . (Sec.7DM,9uslnrss and Professions Code: The Ca c-
� � � � ' ' � - � " � � �� for's Llcertse Low do�s not app7y to on owner of proF,erty
- � � � who builds or improvn}hereon, ond who does such
� � �� � � . - , work htmself provtded fhor such improvements are no�
InTended or offered for eale.lf,however,1he b�ilding or
, � � � � �f . . � _ � � Improvemen}Is sold wifAln ane year ol complQ�ion,tho
� � ' � � � owner-buifdar wilf have fhe burden oiproving tha�be did
� � nof buifd or improve ior fhe purpose of sala.)
I am exemp'under Ser.. .
� 6&P.C.for this`reason
Date
Owner
______----._--IYd$,-"cCT6R"5 NOTES