HomeMy WebLinkAbout1676A WDRKERS'COMGENSATION�ECLARATION APPLICATION FOR PLUMBING PERMIT �
I hereby affirm rhm I hove a cerfifico�e of consent to self �bqyb�q
, insure,or o certificoie of Workers'Compensafion Insurpnce, CE 617(REV.ID/81 J
or a certif^ied mpy thereof(S�c.3800,lab.Cy.',. COUNTY OF LOS ANGELES BUIL.gWG AND SAPETY
P❑olity Nd"�Com�ny ��i1 e v .�`"racT�°'S�Z,S$d �07`�/�
Cer�ified copy is here furnished. BUILDING Q''� �/,,�
� FOR APPLICANT TO FILL IN(PRIN70R TYPE) qDDRE55 �J r��I�G7
Cerfified copy is filed il �� - in e - NUMBER FIXTURE OR ITEM @ FEE
(��pn department.
/'Iy-�7 Q� � WATERCLOSET � LOCAIITY I aL/1
Da�e Applicant � NEAREST �['�♦
CERTIFICATE OF EXEMPTION FROM WORKERS' ?j BATH TUB / CROSS S7. �(./J Q MY1 i�'
COMPENSATION INSURANCE
(This socfien naad not bo complehd I(tb�work lnrolved by $HOWER + owNEe �h
fhe •rmif ls for on�hurtdr�d dollcrs 5100 or Ip7• N'A��
� ( � I LAVATORY qDDRE55
I certify that in the performance of ihe work for which ihis
permit is issued,I shall nol employ pny pe�san in pny manner SINK CITY J; TEI.NO. �.
so as to hemme subject fo the Workers'Compen5ation Lows. p15HWASHER OA
CONTRACTpR � g�
Date applicant CLOTHES WASHER ApDRE55 )
�^'°�OTICE TO APPLICANT: If, after moking �his Certificate of � �/ �
�mption, you should becom¢ subjed fo ihe Workers' SWIMMINGPOOLRECEPTOR / /
.,ompensarion provisions of the la6or Code,you must forth- ��T�� �/1'� (J�U�. �' 'p�� �
wifh cam I with such rovisions 0� 1hi5 e�mif 5hpll be �WNSPRINKLERSYSTEM ,
P Y P P S7ATE a LIC. /� �
deemed revoked. WATER HEATER LICENSE NO. f �Q CLA55 l�.
LICENSED CONTRACTORS DECLARAiION DiSTRicr NO.� �ry� PROCESSeo ev
I hereby affirm ihat I am licensed under provisions of Chopler 9 GAS SYS7EM OUTtE75 4 1�'10.10 fl e..
(commencing with Section 7000)of Division 3 of the Business OU7lEi50VER
II ond Professions Cod�and my�ense is in full force^nd effect. 5 PER Sv57EM FDIAT L �� �.. VAIIDATION �;
license Number �� 3 lic Class� � � � 0-�
FINAL Zj
' �►�.�1 ''p �r� ��"�%��-�'Y' �
Contractor ate BY O
� ❑ I am exempt under Sec. , � �
B.&P.C.for this reason V
Plon che<k fee :'1 6 7.6 A a'
Da�e: , tq
PLUMBING PERMIT ISSUING FEE$ Q �Q g � o �5 �
Signoture .
TOTAI FEE �j
� �7QJ0
Plan check ppplicant �
SINGIE FAMILY • •� �• /G�O u
HOME OWNER-BUILDER DECLARATION Name G 4,1�5"8 7
"��reby offirm Ihof I am exempt from the Con�rocfor's licanse p��@ss
.v for the following reason (Section 7031.5, Busines3 a�d
Professions Code): Cify Tel,No.
❑ I,os owner of the proparty,will do the work and the
structure is not in�ended or offered for sale(Section , -
7044,6usiness and Professions Code). �
CONSTRUCTIOPI LENDING AGENCY
I here6y atfirm ihot Ihere is a construction lending agenry fo�
the parformonce of 1he work for which this parmit is issued
(Sec.3n47.Civ.C.).
kerRfeMr IVvrrtc
lerni�'a/ii�ftJt6es
I certify thal I hove reod ihis applicofion and state ihat the ►
above information is correct.I agree to comply with ail County �
ordinonces and Slate laws regula�ing Plumbing,ond hereby
oWhorize epresentatives of fhis Counfy lo eMcr upon the
���bov men�ionedp property f r ins a tionj�urpos,e,qs
X���� -1�"^i �O� SEE REVERSE FOR EXPLANATORY LANGUAGE
�,'' Signot�re of Permittee - Date
, � � "}-f 1! �4�.-� _- .-
_ �,� .� _t .. . - ' e ..�.►_
R_,(""-"'Vk,,L,N'x. �r V ',, INSPECTOR'SNOTES 42 ���ensyeYLav� fo`tER BUILD[R" � �RA,itON
A� ..k4 CAi MShPECTOR 5 SIGNATURE Q 4 _ .,,h ,
UNDE 4 ��Or -A •�� . � #' `�hot I om er.e pt tom ih C.,.tcc�or'a
UCH P.. ; � tho follow eg rea_on (S�chnn 70J1.5.
� M-
GA�f.�f.G_ . _� � • � 'Business avd ProfBss.o . Cedel.A�y city o co ify wfi'ch
. - q ires a p �t c n iruct. It p o e d ol's!�,
�as vtn r %� � : ,
�,A��`u�rlpaif�Qny sfF�ciure prior�{o ifs (s�.u�N�;.� I o
f OT JiFT 2 N T � " � � � q res the oppf[anYfor such pe.mN fo f re v s gned e rore-
.:k �-_' 'X- :.-rf: ..
'RUNf��C-,fi. �..,' � � ,S - ,_��� � menl fhof he rs hcensed pursuant fo tAe pravisions oF the
��..����7/� Cantractori Lfcense Caw Cha t 9 commencin
Fn�i..r_.; — !'/ � .— . . _.. ( Per ( q�.,i�h
Sedion 70.70J of Dlvision 3 0/�he Business ond Proles-
UTI iT7 CC N�71� , � sions Cade)or thof he is exempi th�efrem crtd Ihe bosis
� '7_�. � �- ��-� (or the olleged exnmpifon. Any violo�ion oi Sat�ion
�Finqi �•��f orc �1�rnie( � � � ���' -- � '" � ^ '�� 7037.5 by any a�eplitanf/or o permif subjects Ih�oppli�
- --i— conf to a civif penalty o1 not more}hon Nve hundred
Z. _.— __��E�� � .�1 f.��, � - . �� dollars($500).:
iNDJ T.�i.i � � , � , �s ❑I,as owner ot ihe propsrty will do the work,nnd
4v✓A r t,�=�,�� �1��- �+ '�� � ��1 j-�� -t - Ihe sir�tlUre is not intended o�offered for sale.
�i..��... . -
'' li ' - {Sac.7045,Buniness andPra/essions Code: The Ca ` �
'��.,1' ..,... �� _. . . _.. � .., , ..... .
. ior's Llcense Low does not opply to an owner ol proper�y
� who butlds or lmproves thereon, and who docs such
�� �� �� ' � ' -�� work hlmsel(proWded fhat such improvements are no�
. , . lnfendedoroffered(orsale.lf,howevcr,fhe6vildingor
' - � �� - ... `� lmprovement!s sold wifh(n one yeor of complefion,fhe
owner-buildarwJll fiave the burden oFproving that he did
� . not 6uild or(mprove fa�.ing pu�poso of sale.J
i _ ...,
... I am 4xemp'�4 � � ,
, 'l ,� � �,�� ���r,__:;. ,
� B&P.C.for ihis�reason �
� •�'� Dote�--.-- —
- ` �
Owner
�---��P,J�PECTpR'S NOTES