HomeMy WebLinkAbout1675A WORKERS'GOMPENSATIONDECIARATION APPLICATION FOR PIUMBING PERMIT {�
I hereby affirm that I hove a certificate of cansent to self �bp,yb�q �
insure,or o certificpte of Workers'Compensation Insuronce, CE 817(REV.10/Bl)
or a certified copy thereof(Sec.3800,Lab.C.� COUNTY Of l05 ANGElES BUIIg ING AMD SAFETY
0�Y N��3�og�Y�+.�e �rw� rr�G7"�'y�d 1.0�
Certified mpy is here6y mished. BUIL�ING
� FOR APPIICANT 70 Flll M(PRINT OR TYGE)
Certified copy is filed w t t 'k1: .f ADDRESS �Y�� � J
1� n d)eportmpent. � u /� NUMeER FIXTURE OR ITEM f� FEE �«AUTV �/y �ny
�f��D r WATER CLOSET ` �`1��n
Da7e Appliconi NEARE57 �
CERTIFICATE OF EXEMPT19N FROM WORKERS' 'L BA7H TU6 QU' CRO55 ST. ry'�Q Y� I
COMPENSATION INSURANCE OWNER ��
(ihis srAion na�d not be compislad�(fhe work�nvolved by StiOwER
Ihr armlf is lor ono hundr�d dallan 3100 or lea. Ml+IL
P ( ) ) LAVATORY A�DRESS
I certify thpt in the performance of the work far which this
permii is issued,i shdll nol employ any person in ony manner SINK � CITY ; ��� TEL.NO.
so as lo become subjed to the Workers'Compensalion Lows. DISHWASHER a
CONTRACTOR �' e� '
_ Da1e Applimnl ( ClO7HE5 WASHER Q
f'��OTICE TO APPLICANL If, ofter making this Cartifimte of ADDRESS Q1 �,y
' mpfion, you should become su6ject lo ihe Workers' SWIMMINGPOOLRECfPTOR
_�mpensotion provisions of the Labor Code,you musi forth- ��T �,h ���, �' ��ij
with comply with such provisions or fhis permit shall be �wNSPRINKLER5VS7EM
STATE t�O� UC.
�� deemed�evoked. WA7ER HEATER UCENSE NO.
! CL455
. LICENSED CONTRACTORS DECLARATION DiSTRiCT NO.� vROCE55ED BY
i hereby pffirm Ihpf I am licensed�nder provisions Of Chopter 9 GAS SYSTEM OUTLETS �0.'Q
(commencing with Sec�ion 7000)of Division 3 of fhe Butiness OUTlET50YER
and Vrofessions Code,�and mY Ilcanse is in full force and�t S PER SYSTEM FDIA El //�Y/�,� VALIDATION �
P '
License Number � Lic Class� a'
�
� (�( � FINAL ��� f'� �j
Contracror � '� ��Date�•�"�� BY �%.'+�,x7��" �
i ❑ I am ezempt under Sec. O
I--
8.8P.C.for this reason . ;`:� �'],�A W
Plan check fee a
Dare: �;e o� o .5 uj
PIUMBING PfRM1T155U1NG FEE$ Z
Signature
TOiAL FEE ' �' � I u a I G S O
Plan check applicont a �� �>�/C,J Q�
$INGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name � O�/�� 5�8'7
i�'re6y offirm Ihol I am exempt from ihe Conlroctor's License Address
s for�he following reoson (Section 7q31.5, B�siness and
Profassions Code): Cit
❑ Y Tel.No.
I,os owner of the prope�ty,will do the work and fhe
structure is not intended or offered for sale(Sec�ion ►
7044,Business ond Professions Code).
COtJSTRUCTION LENDING AGENCY
. I hereby affirm thot the�e is a construc�ion lending ogency for
�he performance of ihe work 1or which ihis permit is issued
(Sec.3097,Civ.C.�.
kermfeMaFieme
tandew'a.4ddre�s
I cerrify ihat I have read this application ond s�a�e Yhat ihe �
above informotion is correct.I agree to comply with oll County
ordinances and 51ate lows regulating Plumbing,and hereby
ou� tze rapre3ema�i�ves oF this Coonty to entcr upon ihe
a6o tione%,pt/b�eu �i pec pur �ses. � �
�9�/ � � ��� SEE REVERSE fOR EXPLANATORY LANGUAGE
���
ignafure of Perminee Date � �
. . .. 1 .. . . _ ._ . . . . _ . _ . _� . .. . . . .
, � ��►��' �Y
-- -�� � .•�.�-� �.,'C��`..r
"` INSPECTOR'S NOTES � O�PiIVER BUI�.pCR DFCI4RAiiON �
"h�d �.µ�� D:Tc INSP=CTOR'S SIGNATURE ' : � .'.. t . ...-...
j �J f f �� e
UND_R S�Ak� Ou. . Y��/G I hereby off rm tho�I am P `mpt from�rn���C n,cuc�';
ROUGH PWU:6�1`; License Law for 1he following reoson (Sectrort 7031.5.
45 F'PR�^ '�j� � - � 8u{�ne:s and Professions Code�.A ny cify or county w'ijch
GAS VCNi � ��.3�- .� ��� , 'reqNires.o permd.fo ponst-uct,aNer,improve,d=molish,
C .. .: • ., � � . . • '� l� ,.o�r�,�pd q �.Str c�pre, pnor;if I�s.r�ssulancf,;also re-
U
HOT WAT� y �{�„k. , � ''�. ,, r � - • -- �— �( �-quires fhe appliEvs�h(or sucfi pehnii ia h!e o signed ctn�e-
_,. ,
PLU/d31t'e�`'IA L . � )))'C�s '���� '�, ^ . �A . ��� ment fhat fie Is Hcensedpursuon*�o the prov sio�s o1 ib=
GAS TCST � _.��fQ'�" Confractor's License Caw(Chopier 9(cammenciny�•�ifh
UTILITV CO.h'OTIPeD , �� _ Section 70F10J o!Dlvision 3 of�he Buslness and Pro/es-
-- --� � — " �� ' � sions Code or f6of he is ezempf Ihnrefrom ond tAe besis
���'c� � ' " •�-� 1or ihe alleged excr�ptlon Ar,y violoi'on ot Sec/ion
FihA� ��,� � �..�#�&r nn �}on�.'..'�-'` : '`� • ... .'..° ��� 703i.5 by any oppllcont for a permi�subjects thr appli- .
--- ' conf to o civil penaNy of nol mnre than fivo hundred
•�.*__� '� .• - � ,,. doffaro(SSOOj.:
MDUST�qt � , ���. , . �'� ❑I,as awner oi the preperty will do+he work.and
N'A�'E q`�^v�ul ��, '� � -- ihe structure is not intended or offered for sale. �
,_�; � � � _ ,,,�� , (Sec.70Mf,Bustness and Pro£essions Code: 7he Cc --
. , ... . . ..,�� r t�� ,_. Tor's Lltonse Lnwdoes nol apply to an owner of prop.rty
� . ., . - who builds or lmproves Iheraon, and wfio does such
-� � -� ��� '�� . _� � wark himseli provided fha�sutb improvements are not
� lntendsd or offered for sole.If,however,ihe building or
� ,.; � .,, , � �mprovemenf Is w!d witMn one year of completion. Iha
� � � owner-builder wilf have ihe 6urden af proving thot be did
-not bulld or Improve♦or}he purpose of sale.j
I
.... .. __�.i�-.
� - i:am exemp`undecSe . ,
'� `� .i.,- J ,.,.i � ,...�. ;, ,
B&P.C.for ihi�reason
"' Dote
�
Owner
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