HomeMy WebLinkAbout1833A , WORKERS'COMPENSATION DECLARATION APPLICATl�N FOR PlUMBING P� Ml
I hereby affirm that I have a cenifimte o4 consent ro self 76A667q �
.ins�re, or o rertificole of Workers'Compensolion InSuronce, - CE 817(REV.10�81)
or a certified copy�hereof a 3800 �ob.c.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
P�oI��Y No�39'9'9c ���Y�'�� � 'f'�Ct �3'y �C� , �-d���
Certifiad copy is hereby furnished.
� FOR APPLICANT TO FILL IN(PRINT ON TYPE) BUIL�ING � /�
Cerfified copy is filed with the county building inspeo- ADORE55
7'ondepariment. NUMBER FIxtUREDRITEM �a' FEE �
,� LOCAUTY ' Q r
Date ^ � ' Appli4oN���C-��f �J_S�y '� N'ATERCLOSET NEAREST '
CERTIFICATE OF EXEMPTION FROM WORKERS' ��� BATH TU8 � ..1� CROSS ST. /l!/yJ0/� � �
t.[1
COMPFNSATION INSURANCE SNOWER OWNER
(This s�dion n��A no1 b�eomplM�d Ii Ih�work Inrolr�d by ���
th�p�rmit li for ono hondr�d dollors(f100)or I�ss.) IAVqTORY ADDRE55
I certify that in Ihe performonce of ihe work for which ihis
pe.mit is isaued,I sholl no�employ any person in any manner SINN � CIiY '�,.�[� �. p. " S"
so as to become subjecf 10 Ihe Workers'Compansotion laws. DISHWASHER Q
�ONTRACTOR � h��,.. l
Date Applironl - CLOiHES WASHER �0 IO D
,�"''nTICE TO APPUCANT: If, ofier making ihis Ce�lffica�e of ADDRESS
' Fnption, you should become wbject !o the Workers' SWIMMINGPOOLRECEPTOR /� � / / 7
�ompensatioa provisions of the Lo6or Code,you must forth-- ��TYC,7F2 Q'ry �l 1O p 4 �7
with com I wifh wch rovisions or this rmlt aholl be �AWNSPRiNKLER5V5TEM
P Y P Pe STATE LIC ry
daemed revoked. WATER HEATER rt.� LICENSE NO. Q CLASS 4�
LICENSED CONTRACTORS DECLARATION w DISiRICT NO. v20CE55ED BY
I hereby affirm�that I am licenaed under proviaions of Chopter 9 GAS SYSTEM OVTLEfS � f(� 0.1��p
(commencing with Section 700p)of Division 3 of ihe 8usiness OUTlEi50vER
� •� t c�.,
i and Profesxions Code,and my Ilcensa�s in full face and effec�. 5 cert Svsient FINAL VALIDATION
License Number � ���3 lic.Clasa�� DATE �/5 ✓y� �,
ny )���`� FINAI ��� ��- U
Confracror �F� Oate��._ BY (/�L�jL�'=�
I 0 �
I om ezampt under Sec. U
B.&P.C,for Ihis reason Plan check fee W
Daie: ' "1 8 3.3 A �
PLUMBING PERMIT ISSUING FEE$
SignaWre • c a a �
S.' � 5
TOTAL fEE
Plon check applicam � • �'7 6 5 p
SINGLE FAMILV � = ���!i-J J si
HOME OWNER-BUIIDER DECLARATION Name
��zreby affirm thol I am exempt from the Conhactor's License qddross a�.� 7��7
_.�v for rhe following reason(Sedion 7031.5, Business and
� Professions Code): City Tel.No.
❑ I,os owner of ihe propeny,will do fhe work and the
shucture is not intended or offered fof sale �Section ,
7044,Business ond Professions Coda).
CONSTRUCTION LENDING AGENCY
I hereby q(firm 1ho1 there is o consiruc�ion lending ogenty far
the puformonce of tha work for which this permil is issued
(Ser.�35 Ciw G).
lender's Nome
lender's Address �
��, �ce�fify thal I have reod Ihis applimrion and stole thal the ►
� above mformotion is correct I agree fo comply wilh all CouNy
., ordinances and Sr�te tows reguloting Plumbmq,ond here6y
�. autkorize rep`e3entatives of ihis Coun�y to enrer upon the
obove-meMioned property for inspecflon purposes.
SEE REVERSE fOR EXPLANATORY LANGUAGE
signatu�Nrse��� oa,e
'� � � ; a.+��w��r4�
� � _ .,�.�r. � - s-� _ wa....,s , � �. �.a .,..�
� -
n�F;tovr,is � ot,ie ira5p �O' SiGva7URE iNSPECTOR'S NOiES O�NNER-BUIL�CR DECLARAiION
--. .-_.__-,.- --- __ .._. ..^ . .
UND�R SLAe 6 ' I hereby affirm fhor I am e empt from 1ne C nnec�n-';
ROL,GH P U1n �, �i� � �— l cense Lov+ for tho follow ng reasan (Se�� n 703L5,
GAS F F'`; - �� • 8usiness o�d Professions Cede^I,qny ufy or co. ty w- h
GAS VF;�.T -� �- requires o permi�to const,vd,alter �mpro demofis.i.
� ' � or repair any sfruaWre,prbr to its.Issuance, olso re-
HOT 1h'ATER HiaTE�J•� _. �_, ' qui�es tF.e appliconl fo�such perrnit fo(ile 6 signed sfo!e-
PLUMBIN,FC:iUkC5� � ' � � ..� � ent iha�h�is Hcensed pursoant to fhe provisioos o/fhe
.... .. .. _ .- .._,-_ __—....__ ..__. ...__..__.. _.�_. _ ..—_.
m
GA5 T"i ia � ..�� .... .. onf�actors License aw e�+f� rommennny�•,i'
—'� - Sedion 7000)o!Division 3 of�he Buslness and P�oles-
UT;LItY CO.h�,7IFIF„_, _ { ' ,
------- — ---f— sians Code)or tfwf he rs axempr 1Mrekom ond the bcsis
__._ ��,� �� � � for the aJleged excmption. Any violo�ion oi Sec�ion
..F�.n'a� .. � �� �r.-.fcr on ��rorr.f� ` � � �---�--' � 7037.5 by any applicant for a permit subjects�h�appli-
. cont to a tivil penalty of nof more/Ron five Fundred
f f � � � � - .. dollors($500).:
iN�USTe;nt ! � ❑I,as owner oi fhe property will do the work,ond
N,�ASTE A�-�OVA: � iha strocfure is not inlended or offered for sale. -�
s�.__.....v..........._,...__..�._
. � � � (Sec.704<,Hostnesz andProfossions Code: The Cc _
• �- �� �� � . � � � - � � lor's llcartse Law does Irof apply to an owrre�of proyerty
... � � - - who builds or improves iheroon, and w{ro does su<h
' � �� �- � � - , � work himsslf provlded fha�such improvements ore no�
� ' Infended or otfered for sale.1(,however,fhe 6uilding or
- , . � . '� . . . lmprovemenl is sofd wilhin ona ysor of completion. the
� owner•lwlfder wil!have the burden of proving thot Fre did
� not butfd or improve for fhe purpose of sale.)
I am e�cemp`under Sec. ,
6&P.C. for this reason
Date
Owner
� a INS°�CTOR'S NOT'e5 � .,