HomeMy WebLinkAbout1834A WORKERS'COMPENSATION DECLARATION qPpLIGATION FOR PLUMBING P- MI
� I hereby of{irm thai I have o certificote of consent Io self �bqgy�q �
insure,or a certificate of Workers'Compensation Insurance, CE 817(REV.IO/Bl) �
or a cer�ified copy ihereof(Sec.3800�,�}a�b,.C.) COUNTY OF LOS ANGELES .�}–� BUILDING AND SAFETY J –^f� �*
P�ollcy N�`�C�ppny .?fK�Q ��� 1 ��G � 2.. � '�–CJ+ ��O
Certified copy is hereby fumished.
� fORAPPIICANTTOFII.L W�PRINTpRTYPE) BUII�ING
Certified capy Is filed with Ihe county building inspec- ADDRE55 r
fiondeparlmenf. NUMBER fIxTUREORITEM @ FEE �OCAUTY "
PP 1 G� � P WATERCLOSET �I�' � r
�a�e ' n u�a�� . � cRossssr. i u n r
CERTIFICATE OF EXEMPTION FROM WORKERS' `Z, BATH TUB �QO
GOMPENSATION INSURANCE OwrvER
{Th4s�rceon n�rd nof M compi�bd if tM work involrod 6y SHOWER �
th�parmif Is for on�hundnd dollms(f100�or I�u.) � �qvATOeY O� MAit
n�orzess
I certify thot in�he parformonca of Iha work for which this
permil is iasued,I sholl not employ any person in any manner � SINK CITV v � �Q! TEL.NO. � S'��
ao as fo become wbjed fo the Workers'Compensafion Laws. DISHWASHER +'•
� I CONTRACTOR � r p'
Dofe oppliconl ' CLOTHES WASHER V�/ q00RE55 '
}��rJTICE TO APPLICANT: If, after making this Certificate of � q
� rtnpiion, you should 6ecome aubject to �ha Workars' SWIMMINGPOOLRECEPTOR ` /� /
...�mpemation provisions af 1he Lo6or Code,you must forlh- ��TY rG�L� V�— L' (rJ O' fY
.. with tomply wkh suth provisions qr this parmil shall ba �AWN SPRINKtER SVSTEM
STATE fj LIC.
� deamed revoked. , WATER HEATER ,.7,n LICENSE NO. 0 d CLA55 �
I,ICENSED CONTRACTORS DECLARA710N w DISTRIC7 NO. PROCESSED BY
I hereby affirm ihat I am Ilcensed under provis�ons of Chapter 9 l GAS SVS7EM Ol1IlET5 d� �
(mmmencing wifh Section 70W)of Division 3 of the Business QUTLETSOVER
� and Profesaions Code,ond my licansa Is in full force and eHed. 5 PER SVSiEM fINAL �/ J VALIDATION
Licanse Number����� Lic Class� DATE � 7/�O a
^,� FINAL y�,� U
Contrcctor -" � e�-I 1-!�"1 BY �7's'L,rcti-w�'� �
( ❑ I am exampt under Sec. �
8.8P.C.for this reason ► W
Plan check fee
�a�0: !,� :'1 8�:4 F z
PLUMBING PERMIT ISSUING FEE S
Signatora „ , n e c •�j
10TAL FEE
. Plon check opplitanl � ', r�.7 E.5�
SINGLE FAMILY �
HOME OWNER-BUILDER DECLARATION Name � ` - " � ���-'����_-'
'�xeby affirm that I am exempr from rhe Contracror's license Addrass D�r.� ���S 7
..•for ihe following reoson(Section 7031.5,Business ond
Professions Code): City Tel.No. �
❑ I,as owner of 7he property,will do�he work ond the
ttrucfure is nm intended or offered fo�sale (Settion ' ,
7044,Business and Vrofessions Code).
CONSTRUCTION LENDING AGENCY
- I haro6y offirm thol�here is a construction lending agency for .
ihe performance of the work for which�his peamit is iss�ed
(5ee.3D47,Ciw.C.).
Lender's Nome ,
Lender's Rddress
I certify thot I have read this applimrion and srate that the ►
a6ove informotion is correcl,I ogree la mmply with all County .
ordinonces and State lows re9ulating Plumbing,ond hereby
authorize raprasen�atives oP ihis Counry lo enier upon Ihe
a6ove-menlloned property£or inspe<tion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
.� ��D �f-��-��
ignoture of Perminee Date
� F� _ � � -
� + ��
w�l •�il�• �+.rr� ��.
�i� - Mr f ...r � •.� �.
a^"-�:'y:,l.�: i %.iE MS- �OR' SiGNATURE INSPECTOR'S NOTES O�NNER-6UILD[R DFCLARATION
UNDERSI.Ae�':'C;RK -�_
I hareby afflrm Ihal I om e empt from ina Conirocror's
ROUGH PLUM�.P1G. License Lm+ for iho £ollov:nq renson (SF l on 70J7 i
GAS F P�tdG � . � � 8usiness and Prolessiom�Code�:Any city v- ovniywlrch
�,
--�-����----�—;— � - � - requires o permlf to consiract,af�er,improve,d=molis!i.
GAS V[�I�
HO'WPT-R H°5.'"^— � . or rapair any sir�cture, prior to ifs rssuance, also rc--
- ,.�=___��'` . . + � quires fhe applimnt ior sucb permii!e f!!e o signed efa�e-
v;Uha9itdG FixrU6E; '� I � � ment flwt he is licensedpurzuon!�o fhe provisicns of fhe
GASiE.`T � - - � Confractor's lfcarse Low(Chopier 9(mmmencing�•�i?h
—�-- � ' Seciion 7000' 1 Division 3 ot the Businoss ond Profes-
U7iLITv CO.NG?�.RED � sions Cods�)or thaf 6e is exe.mpt tberelrcm and�ha besis
—� _�__—
y_ ;_._____ . . C.'._______c7 .__ -.... for the afleged exc,nptlon. Any vrola�ion or Seuion
��� �'� � I�./ e�_}rnrcl � - . . 7031.5 by any appllcont{or a permif subjetls the appli-
— cant to o civil pena7ty of not more�han livo hundred
� •�� dollors(5500).:
'JCUST� t , �, " � ❑I,aa ownar of fhe property will do thc work,and
�V�� �,�.rc,� � ... , �...._.....__.._. _.........__. ...__ _. ...�,..._.,_.._�._,..._. the structure is noi intanded or offered for sale. _.
_,__.._____._,.:':... M...__.,.
� � _ , � (Sec.7044,Buslrwss arrd Profossions Code: The C5 _
'- `` '� -� -� -� � � �. � tor�License Law doss nof apply to on owner of prop.:rty
. . _ , who builds o�improve�ihereon, ard who does such
� � � � work himself prov7ded fhat such impravamEn�s are no�
..,. , � � lntended or offered for sofa.If,however,/he 6vilding or
� � ' , . , .. �mprovement Is so7d�Wlhln orro year of comp!e�iwr,fhe
' . awner-builder will have ihe 6urden of proving h5at he drd
not buifd o�improre for}he purpose of sole.J
I am exomp!undar 5ec. ,
� � B&P.C. for ihis reason
Date
Owner
I^!Sf,CTOR'S NOTES