HomeMy WebLinkAbout1681A W KERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT {�
I hereby affirm tho� I hove a cenificote of consent to self 76qby7q I I
insore,o�a rertificate of Workers'Compensalion Insurance, CE BV(REV.10/81I � U
or o cerrified�mQp�y�ihere'�o}f(S� 3800,ta .C. COUNTY OF LOS ANGELES BUIL G AN�SAFETY LO�� I�
P❑olicy Na.�_(r.7/L[Comp�y V ,�,�
Certified topy is hereby f rnished. BUILDING (�,�
� A/q1 FOR APv�ICANT TO Fllt IN(PRINT OR TYPE) qDDRE55 �.�..J r rr1 '� �
Certified copy is filed w�h c un 'ui � � R� NUMBER FIXTURE OR ITEM (p FEE
tion deparlm�enjl. /�� tOCqL1TV � u
Da1e�(,�Y�AppliSant �� WATER CL0.5ET W NEAREST 1
CERTIFICATE OF EXEMPTION FROM WORKERS' BAiH 7UB CROSS 57. 1Q�'1 1r I
COMPENSATION INSURANCE SHOWER OWNER
(This a�dien n�ed not b�compftl�d It 1he work Involwd by MAiL
fAe permft is}or ona hundr�d dollon(5700)or I���.) � lAVATORV ADDRE55
1 cenify tha�ia the performonm of the wo�k for which this
permit is issued,I shall not employ any person in any manner SiNK � CItY O v��p,�� TEL NO. 6>.
so as to become subject to fhe Workais'Campenwlion Lows. pISHWASHER
!J� CONTRACTOR �` Q�'
Date A licant 9 ou must forth- 55 (��' •
"----,.,.MOTICE TO AVPLICANTPf, after mokin this Certifiwte of ADDRE
CIOTHE WA NER
� jmption, you should become subjacl to ihe Workers. SWIMMINGPOOLRFCEGTOR
��,Y � (rr�a,,,2 3�,.
,ampensation provisions of the Labor Code,y LAWNSPRINKLERSVSTEM
� wiih comply wi�h such provisions or this permil shall be 57ATE � rj�,�� LIC. C Q /'
deemad revoked. WATER HEATER UCENSE NO. I�� CLASS 7C�
UCENSED CONTRACTDRS DECLARATION DiSTRIC7 NO. PRpCE55ED BV
I heroby offirm ihot I pm licansed under provisions of Chop7er9 GAS SYSTEM OUTLETS L a d n�
(commencing with Sec�ion 7000y of Division 3 of Iha Business OUnET50VER �
aad ProfeuioosCade,and my lice�x is in full force and effxt. 5 PEk SYSiEM fINAI �� VALIDATION
'{('�p� � ^��� PATE Cf <✓',3 Y' O�
License Number /✓�1�Lic.Class 1,f 2lGL
FINAL �J U
,�»�c
Con�ractor f � a�e rg 1 y�7 . BY /��)lz � �
I ❑ :'=1 6 8 1 A �
I am exempt under Sec.
U
B.BP.C.for ihis reoson pian check fee ► �' ' ' ' `5 nW.
Date: �
PLUM8ING PERMIT ISSUING FEE 5 � ° �7 6 5 D Z
si9noW,e
TOTAL FEE r- - � �I E.5 Q c�
Plan check applicaM . Q�,� J�a�
SINGLE fAMIIY
NOME OWNER-BUIIDER DECIARATION Name
��areby affirm that I pm exempt from ihe ConiraUor'a Litense qddress
.v for the following reason (Section 7031.5, Business and
Professions Code): Ciry Tel.Na.
❑ I,as owner of the property,will do the work and ihe
shucture is nor imended or offered for sale (Sectlon ►
7044,Business and Professions Code).
CONSTRUCTION�ENDING AGENCY
I here6y nffirm Ihat there is a construction lending agenq for
ihe perfo�mance of the work for which Ihis permit is issued
(Sx.3p97,Civ.C.).
Leedbe"s 14ems �
Landes's Rdd� �
I certi4y that I hove�ead lhis appGmtion and sta�e ihot ihe � �
above informalion is correct.I o9ree�o comply with oll Cou��y
ordinances and 51ate Idws regulating Plum6ing,ond here6y
a ori repre�ent rives of ihis Coumy lo enter upon the
o ve- eMio e o�jer f ins� �on py.yposes.,�
//'//J SEE REVERSF fOR EXPLANATORY LANGUAGE
7�l(4
Signature of Permiftee Da�e
' � ��� ��++rela��. � --•• r
1r�r '+. .�..�+•tir+- . ..�.r-��
- �.r.�...h �.� �.s� �
t��r �� or� iNs S.siGVA7URE MSPECTOR'SN07E5 ��. O�hNERBUILD[RDCIARAiION
�-- ''�. . .. ,
uNoeR s•s.� �� s � 4 � . , . �. .
���--� � � — I liere6y ff�m�thot I nm exe pt�f om�tn� Conlre i�r';
ROl1GHP'Ut � � � Lcense L ✓ for the following on (5�t n 703L5,
GAS F�P,:vG r - ' ��,�7��r� .��;i ` � ' - 8uvness and Proicssrons Code):A y qty or o .tyv.vF,-ch
GAS Vr"hT . f .i� �. s .requires�o permit to const-uct, If �mprove,Aemohs��,
HO'W'ATEF F TLF � �� � � ' � � ;��epair,poy�slructure, prio['�b,Jts i4suance,_also re-
f =-�.— - �.—s.,.Y� ' ,. qvires tfie applicb�nl lor such pe�rri�toYileto slqned store-
PLU"nBIPJ„rt! .�t:•-�� � ' ---t`��� �� ment fFof he is Iicensedpur nt to the provis'cns of fh�
GASTES� iz,l�y.f'�rv' � --` Conlractor's License Law!Chapter 9(commencing�•-i;h
Sec�ion 7000 of Divlsion 3 of ihe Business artd Profes�
UTiLITY rp,h nF e� _ ' — sions Code)or thaf he is exempt therefrom acd the bosis
�:�_ -� Y � t't� '�' �or fhe alfegod excnpflon. An� violo-fion or SecNon
Flnn_ �,i ����' � }�,fn on �rorc[�'� ' ���' �� � 703i.5 by ony cpplicant lor a parmd subjec�s the opp11-
"�--"--"�-�--��`�-'�"`—' "�+ �+.� cont to a civil panalty of nof mare than live hundred
. .:� .,���, i �i ' .,"..:�;..� ':: �-,�_: + dolfars(8500).:
wou r ,ai -�--- —
., � ; •�� . ',:,`t ; ❑I,as owner of�he property.vill do+he work,and
N.�STF."f.' ; � :.. ' ��.—. ,.__ __ ..-..—_—'
� ` : � ' the sirucfure is not inlended or offered for sale.
-1' �� � "!�' (Sec.70M,Buslness ond Professlons Code: 7he Ca � �
'� ' ' � � '" ' '��j��''i' �' tor's Litense Law does nol bpply in on owner ol proH_.,y
.�i__, .__ ,_ _ � who builds or improves thereon, ond who does such
- -� s work himself provided tha�such improvemenfs ore not
7ntendad or offered!or safe.If,however,the building or
. � ' - .. �� lmprovemenf Is sald wilhin one year nf compfefion.fFe
owner-bullder w711 hove the burden oi provrng thar he did
� � nof build or Improye for the purpose of sale.)
:.:4.. ... " . 1
4 pm exemp!under ,
,,_ ' , '� .,�,
��. � � 8 8 P.C.for this�reason
`:
Date
Owner
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