HomeMy WebLinkAbout1836A R ��r : '- � �! _ � . , �_ � � .r. 3�.+�. - �_
�WORKERS'COMPENSATION DECLARATION qppLiCATION FOR PLUMBING PERMIT �
I hereby affirm thoi I have a certiflcate of consent to self �yqy��A �
tinsure,or a certifimte of Workers'Compensalion Insurance, CE 817�REV.IOi81�
o�a cerr4ied copy rhe�eof 1Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUIL IN AND SAFETY
o�Y No����Y � � ��� -r�-���� a ,c��#/�°
Certified mpy is hereby furnished.
� FOR APPLICANT TO FIIL IN�PRINT OR TYPE) BUIIDING . /
Certified copy is filed with the county 6uilding insper ADORESS 1� /•
i' n deport�ent. NUMBER FIXTIJRE OR ITEM � FEE �«AIITY � �
-� ,— ��. Qf WAiER CLOSET Q r
Date AppliqanlL�� NEAREST j�j
BATH TUB CRO55 ST. J ' f�,t
CERTIFICATE OF EXEMFT19N FROM WORKERS' � ZOCi
COMPENSATION Itd$URANCE OWNER
(This s�c�ion m�d rwt b�complef�d if fh�work Imolv�d 6y SMowea
Me psrmM b for om hundr�d dallcn(5100)or Ins.) iqvaroev o ADDRESS
I certify rhot in the performance of the work for which th�s / l
permit is issuad,I shall nof employ any person in any manner � SINK CiTY c(f�1 n�.�, E�' iC�— s'7/
so as to become subie��fo�he Workers Compensation Laws. DiSHwaStiea /� "
I� IGJ QO CONTRACTOR �' Gj���/ /J, .
Date Applicont ` CLOTHES WASHER 0� ADDRESS
,/`^TICE TO RPPIICANT; If, afler making this Certifimte of Q
mpfion, yov should bacome subjecf lo the Workers' SWIMMINGPOOLRECEPIOR �
C17V
l.OmpenSotiOn provisions of ihe Lobor Code,you must forih- �qWN SPRINKLER SVSTEM � ��Y�~
with comply with such provisions or fhis parmit shall be STATE IIC. fl
deemed revoked. { WATER HEATER LICENSE NO. C4A55 �%
LICENSfD GONTRRCTORS DECLARATION � DISTRICT NO. � PROCESSE�BY
I hareby offirm thpi I om licensed under provisions of Chopter 9 GAS SYSiEM OUTLETS /'/') .��o.R
L/
(commencing wilh Sec�ion 7000)of Division 3 of Ihe Business OUTtET50VER
and Professions Code,and my license is in full forca and effect 5 GER SYSTEM FINAL VALIDATION
� � � DATE �� �� �
Litanse Number 3 44 3 lic.Closs�
p � ' , �`� f INAI ��/f, - U.
Contractor�l C� Y r Oate� BY /,irt-n6
�
� O
I am exempf under Sec F
U
8.8P.C.for this reason W
Plan check fee � p.�
oa�e: 1 �'S 6 P, cn
PLUMBING PERMIT ISSUING FEE$ �O Z
Signature ,� ,, i •j ^
. TOTAL FEE "
Plan check opplicant � ` ' "��"�C
SINGLE FAMILY
� HOME OWNER-BUILDER DECLARATION Name - ' � - �� �� `.��
���reby nffirm that I am exemp�from the Contractor's l�cence Address G 9.� %—8 7
..,w for Ihe following reasan (Section 7031.5, &usiness and
�� Professions Code): Ciry Tel.No.
� ❑ I,as owner of the proparry,will do ihe work and the
s�rucfure is not intended or offered for sale(Section � �
7044,Business ond Professions Code).
LONSTRUCTION LENDING AGENCY �
I hereby nffirm rhat ihere is a construction lending ogency for
fhe-perfarmonce of the work for which�his permit is issued
(Sec.3094,Civ.C.). � .
Lemlers FJrnne .
Lmder s ftdHress �
I certify tha�I have reod this oppli<otion ond state thal the �
above information is correct.I agree to comply with oll County �
ordlnances and State lows regulating Plumbing,ond here6y
authorize representatives of ihis Counly to enier upon the
above-menroned properiy for inspecrion purposes. SEE REVERSE POR EXPLANATORY LANGUAGE
d�...�.--n�-a� g-1 l-�'7
Signalure of Permittee Date � � ,
�
������ . _�-•.a.....�, f+�,a.
' • � 1�l� �..�M � fo.�-.- ...� ri s��-.
n�- .� � cni[ iN5_.r 'SS��GNATURE INSPECTOR'S NOTES . ONiIVER BUILDER� C.ARATION
UVOF4 .A3.�b 36R� 1 � ! hereby afflrm ihat I am er.empt from Ine Contrccrcr';
�kOt .iP�U.n: l i # - - � License Law for th� follow��g reason (Serf 7G31.5.
GAc F J� � ����� iT,:'�' ��_�� Business and Professions Codm).Any city or. hy w`�:h
� requi�es a permi�lo conslrucf,alter,�m�ro e demolis:r.
GAS VE�T I � � . �
HOT V�t�7 S F° 1L - or repair ony slructure, prior to rfs issuo�ce also re�
- quires}he oppfitaM�for such permil io lile a signed sto!e-
�PLi n e��.F_RTi a _'___ � - � � .. �� meM fhaf ha rs Ilcer.sed purs�onr ro the pro s ons of fhe
�G�5 JE� , ConlracTor"s Llcense Caw(CMapfer 9(com enc-ny�viph
qUTILITY:'r�.�:;)'1-'..�7__ .__ Setfion 7�0)o(Division 3 of the Bus'rness ond Proles-
f ----- sions CodeJ or lfwl he is euempf tlro`efrom ond th�besis
c7 fo` Ihe alleged excmpilon. Any violalion of Sec�ion
'FlNAt � ' � �•��,.frr on _.1roa� � � 7031.5 by any opplitanf/or a permit subjecfs thc oppli-
---------- , cont fo a tivil panofty af not more fhan live hundred
----_-- � dollan($500).:
'h'oU.':t^.iF.. " . � � ' ❑I,as owner cf the property will do ihe wark,and
VJASiF!•vFRO':n� ' � Ihe strudure is nof intended or offsred fior sala. '
� � � � ' (Set.7044,B�slnoss and Professiorts Code: The Cc c�
� - � � - � '� � � � � for's License Low doos not apply fo on owner af property
� , � � , who 6vilds or Improves fhereon, and who does such
• � �� � � � � , work hfmsalf providerl 1ho�wch improvemsnts are not
� . � )ntended or offered lor sale.!f,however,ihe bullding or
. � _ � � � ` - - Improvemen}Is sold wifbirt one yeor of completion,thr
owner-builder will have iha burden of proving thal hx di�
not bulfd or lmprove 3or fhe purpose of sole.)
I am exemp'under Sac. ,
B 8 P.C.for ihis reason
Date
Owner
Ih.'6?c�.;OFi'S NOTES