HomeMy WebLinkAbout1680A W � 5'COMPENSATIONDECLARATION APPLICATION FC1R PLUMBING PERMIT �
I hereby affirm rhoi I have a certifica�e of consent ro self �yA��q
, inswe,or o certificote of Warkers"Compensation Insurance, CE617(REV.10/BIJ
or a cerfif^ie�dj�co1,.p�yQ iCh�ereof(S�ejc.380�0'^,,.L/a,b_.C.) r ��,// COUNTY OF LOS ANGELES 9UIL01 G AND SAFETY
.P❑olfcy NoY�St(�l��rvTpany.�2J 4�Q S�YW („� � /�y ,/ _�
Certified copy is hereby Fumished. y ��
^ FOR APPLICANi TO fILL IN�PRINT OR TYPE) HUIIDING rm c
�� Cer�ified copy is filed w� t t di 'n e - n�oRESS � ,,,i
ti ndeparimeni. � NUMBER FIXTUREORITEM @ FEE �p���TY (
UateJ��A li on1 { �.+� � WATERCLOSET � rv��
PP 4 CROSSSST. ,(�(i � IV
CERTIFICAiE OF EXEMPTIQN FROM WORKERS' BATH TUB
COMPENSATION INSUHANCE SNOWER OWNER
(This tecfion ns�d not be�ompl�fed if fbe work Involved by MA��
�he permif is for ona kundr�d dollon(S10Q�or leaa.) LqVAiORV ADDRESS
1 certify thot in the performance of�he wark for which this y t .
permit is issued,I shall noi employ any person in any manner SINK � CI7Y ` 7EL.NO. �
so as to become subjec�to ihe Woikers Compensafion Laws. pI5HWA5HER p/�
�, / vC/ CONTRACTOR �' Q,/
T
�-....-�--Dote 6pplicont C�OTHES WASHER
ADDRESS
�ATICE TO APPLICANT: If, after making this Ceri�ficate of �
� rmpfion, you should become subjec� to the Workers� SWIMMINGPOOLRECEPTpR
_ompensotion provisions of fhe Lobor Code,you must for�h- CITV� h y .�J .
wifh comply wifh su[h provisions or lhis permif shpll be �AWNSPRINKLERSYSTEM STATE �,i. LIC. �1
deemedrevoked. WATERHEATER UCENSENO. I �OO CLASS 4 �
IICENSEO CONTRACTORS DECLARATION DIS7RICT No.. ��PaOCESSED BY
1 hereby affirm�hat I om licensed under provisions of Chapter 9 GAS SYSTEM OUTLElS O
(commencing with Section 70pp)ot Division 3 of�he Business oUitE75OVER
. and Professions Coda,ond my license is in full force and effect. 5 PEe SVStenn FINAL �,� /�-y� VALlDATION y;
License Number U���J lic.Class�'..��" �ATE �J �Y 5 Q
FINAL ^ U.
Contractor � Da�e �� 8Y ���s"'"��
O
J ❑ I om exempr under Sea �...
8.8P.C.for this reason W
Plan check fee _-1 6 8,0 A a'
Date: p4UMBING PERMIT ISSUING FEE$ D �5 Z
Signalure �� ' ' ° •
TOTAL FEE � �I�tu ,.7�5 O
Plon cNeck applicant
SINGLE FAMILY � � �� l i;�.i�����
HOME DWNER-BUILDER DECLARATION Nome a g,,� 5_�,�
�''^'3raby affirm thot I om exemp�from�he Comracfor's License Address
N fw ths following reason(Section 7031.5, 8usiness and
Professions CodeJ: City iel.No,
❑ I,os owner of the properry,will do the work ond the
structure is not imended or offered fo�sole (Section ,
7044,Business and Professions Code).
� CONSTRUCTION LENDING AGENCY
I here6y nffirm Ihot Ihere is a mnsiruction lending agency for
the performance of�he work for which this permir is issuad
I5ec 3047.Civ.C.).
YE�st#b FWGe7�e---
lm�dba'a Rddeear.-—
I ceHify that I have reod fhis app�icofion and state thot�he � �
above informalion is correct.I agree fa comply with all Ca�nfy
ordinances ond State laws regulating Plumbing,and hereby
ou rize repre3entativas of this County fo enler upon fhe ,
ab e- enti e p opeqy f r i�tion p oses._ R�
Ko` SEE REYERSE FOR EXPLANATORY LANCrUAGE
Signat�re of Parmittee Dole
a�` � '� ';�5��M` a� - t � �'�
r
� _ . a . _ . .a �.r a��
' _ _ �' .�. . � . a ...�_
` '-" "-'� iNSPECTOR'S NOTES � Ob�iNER BUILp[R�F�ARAiION
D4T- �NSP�T'�R'SSIGNATURF _��...._.��..._, . - 1
LP I� LFPj4G h �-�. 9 /�� - � � 4 � J � '1� k.., , ` : k t.. -
I h reby ff m thai I om . mpr f m ih C. t �tc•'z
RO J i.l—L.5 — # 5y� J � ' ----" L�cense L tor th f II ing n (Se f 70J1..i.
GAS F F NG ' t ���F,�#' -_`�.� � " � Buvness and Profess on (ode� Any ify or.ou rty h�ch
GP�VEP.,7 ' � � � � ' ,�� rapoire p permil�o consfruct,alter.�mpro e demoli'sh,
- ---�_ • ,;\ ,j��dM repair anyS�etYucture. prior jo Its'�/ssu4n6a�nlso re�
HOi v;�i[t F FTh� I ��- 'r � � quiros fhA a`ppFittin%dor such perhn I to�ile a s cJned itn�e�
�
PUJh BIiJG>�7� �-`� " � � �� > , ''� � ment ihah he is Ilcensed pursuan,fo ihe provisions o'fhe
GASTE T �� -��� Conlractor's Ucensv Law(Chopfer 9(commenciny.•�i;h
UTiUTI ^_ ��.�.o_ �f �`�� � Seclion 7008)o!Dirision 3 of the Busfness and Profes
�- - ,.i�,. sloas Code)or ihof Fa is exempfi therefrom ond fhe 6as�s
_. I. , _., .. ._ ; .
� '�� � � � : ` ' `"�� �or the olleged exemption. Any violofion oi Sac�ion
Fl�1ai ��,� �\'`, ,1 n '����.(� ... , , �- � \ 7D31.5 by ony cpplicoM for o psrmit subjec+s the appli-
t , ;, , . .l,. �,;u
------- -���---�=---=—� �.� � ` � cant to o civll p�noNy of no�mare�han live hondred
__ 7�.� ' '� - dollors(5500).:
IN U TCI�:: . ❑i,as owner of?he property wi'�I do tne wcrk,ond
�w__aSTe:.p?p�va�,. � ' F 1 �j 1� the siructure is�ol intended or affered for sale. -
�;`'�n � � -�� �..., , _ `4 (Sec.70M,Business and Professlons Code: The Co, �
i � �`, . . .
ior's 6lcerrse Low does no!apply ro on owner al properry
�.y'�. ,._ � �� -� _ � . who bcriMs or imyrovss}fieraon, ond who does such
' '- , � `, work himself provided ihaf such improvements are not
. lntended or otfered for safe.If,however,the building or
� . � . ��•�,y � � improvement Is sold withitt one year of comple�ion,Ihe
owrwr-bWfderwill have/Be burden ofproving Ihaf he did
nof�Itd or fmprow fgr}he purpose of sole.)
�-.i:.-. ._.. „ .`{.�rti�.
. -* ':.t�-�sr�exgmp!under SeE. ' , .
. 1 t�%.1� . .:�.� .. ,
B&P.C.for this reusan �
r�:
. " .. , Date __._ �
... �,�'�`,
Owner
~ I:!�"�CTUR.'S NOTES