HomeMy WebLinkAbout1832A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �
I hereby affirm ihar I hove a certificate of consent to self �bqyy�q
.insure,or a cerlifimte of Workers'Compensotion Insorance, CE BV(REV.IO/el)
or a certif,iqed ropy thereof��3800 lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No(1�,Company �z y� - ~�"rac �� � �' 4 ��,�07`�2I
� Cerlified copy is hereby furnished.
� FOR APPLICANTTO FILL IN(PRWTOR TVPE) BUILDING � � P '
Certified copy is filed with ihe taonry building inspec- A�DRESS
tion departmenl. . NUMBER FIXTURE OR ITEM (� FEE LOCALITY �
�_ ' C:�cr' {�I�• + r
Date qpp��Sa�� WATERCLOSET D NEAREST 1
CERTIFICATE OF EXEMPTIpN FROM WORKERS' BATH TU8 CR0.55 51. I y
COMPENSATION WSURANCE SHOwER OWNER �,-�
(Thk��etion n��d no�6�compl�hd if th�work involwd by MA��
Ih�p�rmit is!or on�h�ndr�d dollon(5100)or I�u.) tqvnToev a�DRE55
I tarfify that in the performance of Ihe work for which this -
permit is issued,1 sholl no1 employ any person in ony manner r SINK �i a?j CITv y � � T l.
so as lo become subjecf to�he Workers Campensation Laws. DISHWASHER
.. I Q CONiRACTOR �' �r J �
Dafe Applicanf f CLOiHE5wA5HER � ADORE55 -
r`�`�]TICE TQ APPUCANT If, of�er mok�ng rhis Cerr�flcnte of Q
• mption, you should become subjecr to the Workars' SWIMMINGPOOLRECEPTOR / ,I^u
�ompensatlon provisions of�he labor Code,you m�st forth- ��TYC� r V.Q,� 5!�
wilh comply wifh such provisions or ihis pe�mif shpll be �AWNSPRINKLERSVSTEM STATE LIC.
deemed rovoked. WATER HEATER + LiCENSE NO. CLASS
IICENSED CONTRACTORS DECLARATION A Di5TRl4T N0. PROCFSSED BY
1 heraby affirm thot I am licensed undar provisions of Chopler 9 GAS SVSTEM OUTIETS V 1S
(commencing with Saction 7000)of Division 3 of Ihe Business OUilET50VER ��
�. and Professions Code,ond my licanse is In full force and affect. 5 vEk SvSTEnn FINAL i VALIDATION
p � /��, OAiE %�?� �s� Q�
Litense Number���Q 8.� Lia Class_�_
[ Q�����'`j FINAL � � U
Contracror � • Date� 8Y %r�'� � �
I � O
f am exampt under Sec. `-1 8,2 A W
B.&P.C.far this reason
Plan check fee �,a � r � �5 n,
Do�e: PLUM6ING PERMIT ISSUING FEE$ 0 Z
Signo�ure ( � c 7 b.5 0 —�
roTa�Fee
s = <-�(z�i�'�
Plon check opplicant
SINGLE FAMILY �r.� ���7
HOM€OWNER-BUIIDER DECLARATION Name '
'�ereby affirm ihat I am exemp�from ihe Camracfor's license Address
..w for fhe following reoson(Seation 7W1.5,Business ond ,
Professions Code): City Tel.No.
❑ i,as owner of the property,will do Ihe wwk ond the
structure is not intended or affered for wle (Section �
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby nffirm thal fhere is a conslructian lending agency for
the perfwmonce of the work for which Ihis parmit is issued
(5ea.�!Q#,Eis.C.).
ten�8*'s Rem� �
LarntaYs RdBress
I cerfify fhot I hove reod this opplicotion ond state Ihat the ►
a6ove informotion is carrect I agree�o comply with all County �
ordinonces and S�ofe laws regulafing Plumb��ng,qnd hereby
Quthorize represeNatives of�his County ro enter upon Ihe
above-mentioned properiy for inspenion pu�poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
�2,.���_ �Yr,�.} AQQQ - � .
Signature of Permittee Date
T�l4 '71+�'1�!'4�Qi MIO�1?/��!!'!�A . � . _ . - . -
F=�rµ�:��'s�� ,ar� iN5 iOR'SSiGnIATUae INSPEQOR'S NOTES OWNEP,-BUILDCR DECl4RATION
__.__�—._...----- .. _ ., . .
UNDER�iA&NJ�� � I .`�" ' � �
I hereby affirm ihat I am e emp'from Ine Contresror's
x
ROUfH P U^.^! I � . �- ' License Lnw for ihe follow ng reason (Sec� 7031.5,
t
�� ci} or o I � ,4;�.ti
GAS F PI ��� 1 �, � �' � � 8usiness ond Proless�ons Cedt:Any y y
�.kS VE,"� � �� j � . j . . , requires o permif fo mns�rurt,al�er,impro ,demolis!i,
- — � ' � �.ar repair bny strualure, prior fo lls Issuonce, also re�
HO7\NA7cR H�"<�,T�:'��_�_ � � quires}he applicanf for such pe�mlf}o(ile o signed s�nle-
7LURai JC'F'K liF- � ' ' � I �� - � � • menf thathe is licensed pursuon;to Ihe prowsions of�ha
GA TESf �� /+4/fffY' I � Confroclor's Llcanse Low iChe;nter 9/commrnciny�•�i^h
UT�LiTY CO 1'�T�.rIE�j —sf SetTion 7000)of O�vision 3 of ihe 8usiness onJ Profes-
-----I � sions Code)or tbat Fe is axempt fhxe#rom ond Ihe basis
_______.._ _ --7 - !or the olleged exn^ptivn. Flny violo�ion ci Section
F"ti�A� T!i.�fcr _i�rouf �� ' � � � 7031.5 by any applicanl for a permif subjects Ihe oppli-
------� -- tant fo a tivil penolfy o(nof mare�han five fiundred .
_----------- ... . . dolfars(5500).:
W�UST::IA�_ - - ❑I,os owner of Ihe property will do+he work,�nd
VdP,57[l�cF'�Jb'c.. . ' . . —__—__._____.__.—_.____
_„ _.�, the slructure is not intended or offered for sdle. —.
- .� - -. � , ' (Sec.70M,Business ond Professions Coder 7he Cc .
� � � � . � � � ' . � ' ior's LI[eme Caw does rrot epply to on owner of proparfy
. � � . . � who builds or impraves thereon, ond wfio does such
' - � �� � � � � work himself proWdad ffia�suth improvements ore nol
lntended or offered lor sale.If,howeveq ihe building or
� � � . , , � . improvemenf Is sold within one year of completion, fhe
� � ownervbui7der wll!have the 6urdert of proving fhm he did
� not build or improve{or fhe purpose of sale.)
� I am exemp!under Sec.
._ B 8 P.C. for this reason �
Dote
Owner
� � IN"PcCTOR'S N07E5