HomeMy WebLinkAbout1828A WORKERS'COMPENSAiION DECLARA7iON APPLICATI4N F4R PLUMBING PERMIT {� ��
I hereby affirm that 1 hove o rertificate of consent to self �b,qyy�A �I
insure,or o cerfificole of WOrkers'Compensvfion Insuronce, CE 8I7(REV.10i811
o�a ce�tifie��d co�py(�therejof S�ec 3800,lob.C.) COUN7Y OF L05 ANGELES BUIL ING AND SAPETY
PQol�icy Nolr�C�rRpany - � (J �.y�r, 12 �-�/J1 ��
Certified copy is hareby furnished. � �`�" �S� J ���
� FOR APatICANTTO FILL M(PRINTOR TVPE) B49tDING /_
Certi4ied copy.is filed with the county building inspec- AAORESS ��3 r�`j )� /
NUMeER iIXTURE OR ITEM �pCAUiY
� n deparfinen�. /} / � FEE
Dole ^ ��� qppl�iGant �� �•'�r 1 �2. WATERCIOSET L � NEAREST J r�a Qr
CERTIFICATE Of EXEMPTION FROM WORKERS' � BAiN7Us �Q ��u ST� �4R I'�
COMPENSATION INSURANCE SHOWER OWNER
(ihi���ction nwd nol b�compbrod if fh�work Involved 6y MAi� '�
fh�p�rmit 4 for o�a hundr�d dellan(ST00}or I�rs.) LAVATORV � O� ADDRESS
. I certify ihof in Ihe performance of the work for which ihis � .� /
permif is issued,1 shpll nai employ ony person in ony monner ' SiNK �jf CIN /� +h Q_ ,N .
so as to become subject to the Workeri Compensotion Laws. �"
', DISHWASHER CONTRACTOR ��^�`��r. �
Da7e Applicqnt � CLOTHESWASHER ADDRE55 O �n�,
�� �'nJICE�fifj---APPIICANT: If, ofie.m❑king this Cenificare of Q
� M1iption, you should become subjen lo ihe Workers' SWIMMINGPOOIRECEPIOR -
wmpensation provisions of ihe Labor Cade,you musf forth- CITV � f y�, E�7 , ��/' J/�
wifh comply wilh such provisions or ibis permif sholl ba �AWNSVRINKLERSYSTEM J�CV/V
S7A7E / i��,
deemed revoked. WATERHEATfR q LICENSE N0. . ( . C1A55 � 'p
LICENSED CONiRACTORS CECLARATION V DISiRICi No vROCESSE�Bv
I hereby affirm Ihat I om licensed under provisions of Chapter 9 GAS SvSTEm OIJTLETS . Q�
- (commencing with Seclion 7000)of�ivision 3 of the Business OU7lET50vER �� Q\�
i and Professions Code,a�my license is In full force and effecl. 5 PER SYSTEM FDIN�L � `�, �,a..� VALIDATION �„
License Number ' � Lic.Class�.)1U ` �
/� FINAI
Comractor / C�1 el ././MDate� BY ��i�n��� �
I � �
I om exempt under Sec OO
B.&P.C.for this reason ► W
Plan check fee
Date: �'
�� PlUMB WG PERMIT ISSUING FEE a � %�-�'� £���'Fl Z
$ignalu�e , .
iOTAL FEE i�° • • • •5
Plon check applimN � a • /6,5(j
SINGIE FAMILY
„� HOME OWNER-BUIIDER DECLARATION Name n . �:.%;=S j�?
� greby affirm�hm I am exempi from�he Contractor's License Address ��!,� '�..�7
_„w for the following reoson(Section 7031.5,Business and
Professions CodeJ: City Tel.No.
❑ I,as awner of fhe properfy,will do�he work ond fhe
sVuc�ure is not intended or offered for sale (Section ,
�7044,Business and 7rofessions Code).
CONSTRUCTION LENDING AGENCY
I here6y nff'rrm thoi ihere is a cons��uclion landing ogency(or
the parformonce of the work for which this permit is issoed . �
(Sac.30R7.Civ.C�.
kerdaYs lOt�etr
6enda�'y ArJtltees
I cerfify ihai I have read ihis applicarion and sfale ihol the � ,
ahove information is correct I ogree to mmply wilh oll Coonty
ordinonces and Stote lows reguloting Plumbing,and hereby �
aufhorize repre�enia�ives of ihis Counly fo eMer upon the
obove�mennoned property for inspection purposes.
SFE REVERSE FOR EXPIANATORY LANG!/AGE
-�'7�a�� --/1�-8
Signature of Permittee Da�e .
���� 'na'.-`�'.,�„�`ti a�•
- � � +� �� 4 ���_�~ +�rrr
n�rriova�s���T�o.;< in+sPecro,'S sGNntuae IWSPEC70R'S NOTES O�AlNER-BUI�DeR�FCI..4RATION
UN�=R SIAE'lrO�:i` � I � I hereby affiFm that I o .xempt�from rhe Co�•rcUc•;
ROUGH?LUIJ:'�:.• t_ . ' Licensa Lcw for iFe foilov+'n3 reason (Se.f n 7031.5.
^,.45 F 9'J:_ __: i y� �� " ___ Susiness and Prolesvorn Code):Any<ity or o rfy w9�ch
—I �--�- requires o pormil Fo consfruci,aHe�,improve,demolis.ti,
GESVEN7 � . � .
HOi WATEf;.H;ATE' i - , I — or Iepair,any sfruc}ure, prior fo ifs �ssuan�e, also re-
_ ___ quiras fhe oppJicont�for such permil ho file o signed sinfo-
�P,�Ih,_IIdG F��xtUR:t I � � � men!lhal he is/iconsedpursuant fo 1he provi,ions of!he
� '-� � Confracfor's License law(Chc ter 9 commenci� -•I'h
GAS i65r . , P ( 5�
UTILITv CO.NOi7PlE`. � Secfion 7Q00)o!Olvision 3 0/fhe Business ond Proies-
-------- -- — � sionz Code)a�11wf ho is ezempt fhc>re/rom o�nd th=besis
- c7 ' � for fhe afleged exernpHon. Any viola/ion oi SeUion
Fi�'AL - � ����rr on _.i�ronl � � � ' 703i.5 by ony applicant lor o permif subjecls�he pppli-
--------------- , tonf to a civil pena7ty ol not more than five hundred
_______ _____. � �� doffars(8500).:
IM1DLST-'`.L - ' � . . � ❑I,as owner of Ihe property will do the work,and
w\T. aii'�OV4_ � � � � �}he sfrucNre is nof intsnded or offered for sale. — �
�._.,........,._...,._.__..._... �. . ., . _
' � � � . (Sec.7044,Bvslness ond Pro/essions Code: ihe 0. .
� �� - � � _. � tor's Litense Law does not opply to an owner of proprrry
� � • - "- - � who builds or improves fhereon, and who does such
� � � - �- � - � � � - , wotk himself prorlded tho#suth improvements are noi
In�ended or affered for sa(e.If,howaver,fhe building or
� ,' � - � � . improvement is sofd wifhin one year of compleflon,fFe
- owner•burfderwill have the burden of proving Ihot he did
, not buifd orlmprove(or the purpqse of sole.)
`. t am exemp!under Sec. ,
B 8 P.C.tor ihis�reason
Date
Owner
��-.^_ IhJ�FECTO�C'SNOT85 �