HomeMy WebLinkAbout1679A - COMRENSATIONDECLARATION APPLICATIQN F4R PLUMBING PERMIT {� �.
- I hereby affirm ihat I hove o certifica�e of consent to self �yqyb�q
insVre,or p certifimte af.Workers'Compe�sotion Insurance, CE 817(REV.10/87) LJ
or a cemf�ed co y rhereof(Se���o0,l .C.) COUNTY OF lOS ANGElES BUILDING�A�yND SAFETY
P�ol�cy No.O�ampany �Q V �"{T� � ���r�
{ertified topy is hereby f rnished.
� FORAPPIICANiTOfILLIN(PRINTORTYPE) BUILDING '-¢- �+
Certified copy is filed wi ,t�p i in nsp AODRESS rI�/ ,/VJ
t���i444,,,ndep,a1r�t���}}}@@@nL 7� Nl1MBER fIMUREORITEM Q FEE �pCAtlTv �
Da�e r�App�iconf ( � WATERCLOSET NEAREST f/+ r�
CERTIFICATE OF EXEMPTIQN FROM WORKERS' Z BATH Tl1B / GROSS 5T. / /Y4Q {�
�
COMPENSATION INSURANCE SHOWER OWNER �
� (Thb section mod not b�complehd if the work�nvolved by MAiL
fh�pormit is for onc hundr�d doflors(5100)or Issf.) LqVATORV ,(� ADDRE55
1 certify that in the performonce of Ihe work for which this �
permit is issued,1 shall not employ any person in any manner � SINK CITY v� �(�� iEL.NO. 6,•g�
.so os ro become subjecr�o the Workers'Campenso�ion Laws. DISHWASHER �
CONTRACTOR ,4//
Date ApplimN fLOTHES WASHER ADDRESS �y J �}�
,."�'OTICE TO APPLICqNT: If, after making rhis Certifiwte af p 4+ �+ "'
mpfion, you should bemme subject to Ihe Workers' SWIMMINGPOOIRECEP70R CITY (/y N .
_.,mpensafion provisions of fhe Labar Code,you must forth- LqWN SPRINKLER SYSiEM `�'reJ�
ith comply wilh such provisions or this permit sholl be STA7E / p UC. /►
deemed revoked. WATER HEATER UCENSE NO. / �p C1A55 ���
L�CENSED CONTRACTORS DECLARA710N DISTRICT NO. PROCESSED BY
I hereby affirm ihp7 I am licgnsed undar provisians of Chopfer 9 GAS SVS�EM OUTLETS /� 7M A\O n p
(commencing with SeUion 7000)of Division 3 of ihe Business Ou7lET50vER � ��,t
' and Professions Code,ond my licanse is in iull force ond effect. 5 PER SvSiEnn FINAL VAUDATION
Litense Number •�0�� Lic.Class G 3� DATE � ,' �� �p�
9�- y 7 BYA` �/'�"""" U.
Contractor E �f �� Da�e ' � '�
K
� ❑ I am exempt under Sec �
8.8P.C.for this reason W
Pfan check fee ► n,
Dale: pLUMBM6 PERMIT ISSUING FEE$ . '`"� 6�.9 A Z
s�g�ar�,e t:� o . e .5 �
TOTAL FEE "
- Plan check applimni � '.r. ']6,5�
SING�E FAMILY
HOME OWNER-BUIIDER DECLARATION Name � ' " ����-J�
'`���reby affirm�hat I om exempl from�he Contractor's License Address Q Q,� ��$�]
�for the following reoson(Section 7031.5,Businass ond
Professions Code): Ciry Tel.No. � �
❑ I,as owner of the property,will do the work and the � ,
struc�ure is not imended or offered for sale (Sedion
704a,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY
I herBby nffirm fhot there is a construction lending oge�cy for
the performonce of the work for which�his perm�t is issued
{Sac.3047,Civ.C.).
Lxnd�'�
le�rcler'a hdd�sa -
I ceriify that I have read�his opplicotion and state that Ihe �
a6ove informotion is mrrect.I agree�o camply wilh all County �
or inances and S�ate laws regulotinq Plumbing,and hereby
a orize represen+ativesnof Ihis Cau�ry fo �er upon Iha
�ve- fi3' �'��T'sp�an y'�os 5.
���L.�i Z��'��i�[/l.V ' l'��"�j SEE REVERSE FOR EXPLANATORY LANGUAGE
Signarure of Permirtee Date
��'� �IMiA�Ll1'�!�}�4 !�f i1�1!'4�� , ._. . ..�.•.,,.� -
- - � - _. ��_ � ,. ,.�,._. . .'
�F$ '?J,�.I�.Y. �•,- �'TF INSP'TpR'SSICNATUf IN$PECT�R�$N�h$�� .' ��/��(�1Er�,-8(JI��L(Z`fF�l..4(Z�I�(�ilV�
i,
. �,�T ` . .. , . � -
:y__'- • � .,. . .. . . �.
UN�CRSLA6�JvOwk.T� .' `
3 � �I hereby afflrm�th !I o re pt'r m'1�� CenrmUor'a
RCUGHPWACnu ����( r , �. � ,� ' —i� ' License Lnw for the fo�lo�ving roason (Sn�fnn 703L5,
GAS P�PMG I � � 1T � � ' Business ard Professions Codei�qny cHy or counry wh!ch
t_.p._ __
� ,.
GAS VEIJt ��� �` � • �. �� ' � �requires o permH to.consiruct,alter,Improvc�,d=moNsh.
� , r -, �-nr repai�,6ny a2fucfure, prior� Fts JssuanL�e�,alsu re-
HOi wa7ER Hra�-� � ��.^_ ' - � • �� � � � q'uires The appiita`nf ior such perSnif to(�le'a sit�nod stn�e-
vtun�5nd�vixru„.;�� i-� �'-' �� � ' - �" men�nc��he is hcensad pursuonf ro fhe provisrons of rhe
, ^
� ._..
Ga5 ie^� —T� CantrocTor"s Licanso Law(Chep�e�9;mmmenc ny�•-itb
lJ7'�ITY:.0 h'.7IF�;; i .,` �� Section 70D0)of Div�cion 3 o/Ihe Business and P�ofes-
--------r-.—`-- . . �y � , sions Code)or ihof he is exempt therefrom crtd tbe bosis
; }� �� '-""' for the oUeged excnpiinn. Any violafion ai Seclion
.. f
FINAI ,��� .�•����`:�° . . —� �..� �•; �.,.. . ' ------i.� '.. 7031.5 by anY opPlicoM ior a permr�subjecis/he oppli�
� t � ,���„�t
-------- � � cant to a civil penalty of not mare fhan l�ve hundred
'.Y�.�',-- � , dollars(5500).:
�,NDJSTR�P � ; � . � ❑I,as owner of the preperty will do the work,and
��S�F `�`�� ��._ � ' " "' = . • Ihe siructure is noi Intended or offered far sdle. _.
'�-'� `'�t�_: ($ee.7044,Buslness and Pro(essions Code: 7he Cc :
..-`.::�`' ... . � ' ... �.`..f.:. -. .. '—��^--- tor's Lltertse Law does not oppl y to an owner of prot_.iy
� � who 6uilds or improves thereon, ond who does such
"' - �" - �� � ♦:-�'�_ '� work himseff provided fhaf such improvamenfs are nm
lnfended or oHered for sole,If,however,the 6uilding or
- �� ,,.. � • + imptovement ls sold wlfhin onm year of compfetion,�he
owner-6ullder will ftave fhe burden ofproving that he did
- nof build or fmprove for}he purpose af sala.)
� �ti A'�:I am�Remp!under�y��., �, ,
\'ti ; 7�.
B&P.C.for thisveason
Dote
�\
Owner
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