HomeMy WebLinkAbout1837A � SATION DKLARATION
I hereby oft��m ,�a���a�e a cerrificote af consenl�a=e�f ,�,�„a APPLICATION �OR PLUMBING PERMIT
lnsure,or o cerfificate of Workers'Compensafion Inswance, CE B17(REV.IOi81� � , � .
o�o certiFl�ed�c�opqyQth�epreof�.3600�,L+ab.C.) (` / COUNTY OP LOS ANGELES BUILDING A)N�D SAPETY �y
P�oI�cY No(�1�CLLC4fm¢ony�]�G�$�IJYKI I' �'"f � Q '� a/
Certified ropy is hareby furnished. BUILDIN6 //� �-}�
� FOR APPLICANT TOFILI lN(PRINT OR TYPE) qDDRESS [�` / J�I��I J V
Certified copy is filed with fhe county building inspec- NUMBER FIXTUREOR ITEM @ FEE
'on departm nf. 1� IOCAIITY pl��
Da�e ^ `r� Appli4anf ` L�� ���+ WATERCLOSET � �
NEARESi
CER7IFICA?E OF EXEMPTIQN FROM WORKERS' � eA7H TUB a CROSS S7. /, IF �
COMpENSATION INSURANCE SHOWER OWNER �
(This�ecNon ne�d nef 6a cempfr�sd(F fhe work lnvolved by ��i
tM�p�rmif i�for on�hundred dollars(f100)or I�as.) iqvai0ev qoDaeSs
I cenify�hot in rhe performance oP�he work for which�his
permit is issued,�shall not employ any person In ony manner $iNK CITv �' Et.N . �y7.
so as to bacome subjeci ro the Workars'Compensation LawS. DISHWASHER
CONTRACT02 i .�j�,�r �1�
Date !pplicanf ! CLOTHES WASHER qppRESS D Q �''�'a �
,O�"OTICE TO APPLICANT: If, oftar making this Certificote of SwIMMMGPOOtRECEPiOR
' mption, you should become subject to �he Workers'
��mpensation pravisions of the Lobor Code,you rt1u5�forih- �qWNSPRINK4ERSYSTEM CITY Q �n r^�i/,�, T �
wi�h comply with such provisions or ihis permit shall be STATE tiC.
deemad revoked. WATER HEATER /� LICENSE N0. Q CLA55 �
LICENSED CONTRACTORS CECLARATION �V DISTRIC7 NO. PROCESSED BV
I hOreby affiim thot I am licensed undar prorisions of Chapfer 9 GAS SVSTEM OUTLETS /�
(commencing wifh Seclion 7000)of Division 3 of the Business OU7lET50VER ��
and Professions Code,and my license is in fu�l force and effect. 5 PeR SVSTeNt FtNAI VALfDAT10N
� Litense Number �I�u� Li[.Class_fe� DATE �f (� ��; O
y/�, �� � FINAL (J,
Contractor� �� �.�..Date_.[�LL� BY ��ti�^r"''�
� ❑ �
1 am exempt under Se<. �
B.BP.C.for this reason � W
Plan check fee q
Dafe: p�ury�gWG VERMIT ISSUING FEE$ � ` � F'��7'4 Z
Signature n r s
TpTAI FEE +'-° ' °5
Plan check applicani I •- � >'�.�J��
SINGLE FAMILY
�,,, HOME OWNER-BUILDER DECLARATION Name e� . � „ ' �i�
� ereby affirm that i om ezempt from the Controcror i License qddress �
.w far the following raoson(Section 7031.5,Business and 0�,� 7–�7
Professions Cvde): City Tel.No.
❑ I,as owner of�he property,will do the work and tha
slrucfure is not intended or offered fo�sale (Section �
7044,Businesa and Pro#essions Code).
CONSTRUCTION LENDING AGENCY
I here6y affirm ihot there is a consrruction lending ogency for
. fbe performance of the work for whlch thls permit is issved
(Sec.3097,Civ.C.).
I+m+d��y b–�– —
lendar's Addaeu -
I cenify ihot I have read this oppli<arion ond siote Ihat ihe �
above informaHon is corrsci.I agree�o comply wilh oll Couniy
ordinances and Sta�e laws regulaling Plumbing,and hereby
aothnrize represento�ives of rhis County to enter upon the �
abo�e-mentioned property for Inspecrion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signarure of Permittee� �
�_-� –
` � �+wr.a.�+��
_ „�i r!� �4/.,.�nk.rw A.. +r.�!�
�_�..�.i a��rF w�.'!#�"
P-rr.'Jv:,;:3�� oAt[ +r,S�E OR' SIGNATURE INSPECTOR'S NOTES ON/IVER-BUILDER C�ECL�4RAi '`
UNCER �Pl O;<i � -.—�-- — .' �i�heroby offirm ihol I om e. .�pt fromvine Cont��ctcr's
aOUGH P L� i�'G i �I. � � License lan for tho fol�owYeg reoson (S��Non 7031.5.
G?5 F��.FI J � � ���"� y2 _ Business and Professions Code!:Any cUy or munty w°:�cfi
Gn5 VEP.' � .. � � ' ( . ' k reqmres o permit to mnstruct oHer mpro�e,d�mol s.h,
. or!rapmr any sfrudure, pnar fo ils Issuo�cc, also re-
HOi wt,i b nT�`_[. -�` �_—��� � � � �� qoires 1he applicanf for such perm�llo file a signed stc!e-
PWMBR i 7 i'� - � � • ' � � ' � menf fhvl he Is lmensed porsoan'to lhe provrs'ons of�he
�GAS'E 1 �I�,yj�I � Confracfor's litense Law(Chop�er 9(commenc�n j��•i+h
uti�i7v c� ti�ii :� Section 7000)of��ws�on 3 0l ihe Buslness ond Profes-
--—1---. � . sions Code)cr that he rc exempt fbsrefroan ond the basis
� �-7 � for th� olleged ezenption. My violo�ion o� Satlion
.F'�ql (rrfe, a,. _i�ruref � '— -- 703i.5 oy any opplieant for a permif subjects the oppii-
-- — . cant to o civil penalty of not more�£ran five huneireA
� � ' ' . dollars(8500)
N >T L ..--`��--_----- ' ❑i,as ownar e�rhe prope�ry�N II dn�h�wnr�,end
V�?_��� J, x��.4 :,. ,,.�� � �� Ihe structure is noi INended or oHered fcr sole. -�
. . . , (Sec.7044,8us�ness and Professions Code: The Cc .
� � � � � '' � - tor's License Law does nof apply to an owner of prop�rty
� • � . . ` wfio builds or improves lhereon, ond wbo does zuch
��� � ��- �� � � � � ` � work himself provided 1haT such improvemenfs are noi
- � tntended or offered for safe.!f,fiowever,the buifding or
. � ' , . 7mprovement ls safd wlfhtn one yeor o1 ea�npis�ion.the
� � owner•6vildorwilf hove fhe burdeo olproving thaf Fe did
^^� not 6WId or Improve for fhs purpose of svle.j
I am exemp!under Sec. ,
B&P.C.for this reason
Date
Owner
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