HomeMy WebLinkAbout1674A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �
I hereby affirm thar I hove o cerfificate of conseni to self 76A667A
. inwre.o�a cc�lifimfe of Workers'Compensa�ion Insuronce, CE 817 1REV.10/el)
o�o ce�tiiied cop�yi��herepoF(Sec.�3,800,Lob.C.) /� COUNTY OF l05 ANGELES BUIL ING AND SAFETY
Q�yNoQ��O/'�-iCom��(y S�r't�v irt7r�[l �,C, .� � � ��
Certified copy is hereb furni8hed. BWLDING �
� FOR AD7UCANT TO Flll IN(PRINT OR TYPE) ADDRE55 rm i�S
Cerrified mpy�s filed h t �p �dL!�� NUMBER Fi%TURE OR ITEM � FEE
iion departmenL �� �aA��T� "'
� WATERCLOSET � NEAREST � �a� �1
Da1e� PPlitant
CERTIFICATE OF EXEMPTION FROM WORKERS' lj BATH 7UB !Z C0.055 5T. � yyt i
COMPENSATION INSURANCE SHOWER OWNER
(This sedion n��d nof b�complal�d�f th�work fnvolvod hy MAR
Iha pumiT is for ons hundnd dollan(5100)or I�ss.) iAVn70Rv z nooae55 y
I certify thot in the performonce of Ihe work for which ihis SINK b/' �
pgrm��is is5oed,I shall nol empby ony person in any manner � �/ ��TV v; El.N
so os 10 become subject to the Workere'Compensotion Laws. DISHWASNER
CONTRACTOR {+S'G
Da1e Appli[ant CLOTHESWASHER �� qDDRE55 �
/`*DTICE i0 APPLICANT: If, af�er making this Certifitate of SWiMMING POOI RECEPTOR
.mption, you should 6eceme subject to the Warkers' aTv ro��TE.
�ompen5ation provisi0ns of ihe Labor Code,you musl fOfth- �qWN SPRINKIER 51'STEM
i�h �omply with such provisions or Ihis permit sholl be STATE ` Q CLA55 G
daemed revoked. WATER HEATER LICENSE NO-
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm ihot I am licensed under provisio�s Of Chqp+er 9 GAS SYSTEM OVTlETS /� �
(commencing wilh Section 7000)of Division 3 of fhe Business OUilETSOVER
I ond Professions Coda,ond my licanse is in full fate ond effect. 5 PER SVSTEM FINAL yALIDATION
� ��3C+J Sr�L2� DATE C r2-�' f`r� ' O
License Number lic Closs
FINAL �,.,.. U.
CoNroctor -� � Date�y� BY �,l�r+�•,' d' a.
❑ I am exempt under Sec � V
B.&P.C.fo�this reoson � � pW,�
Plan check fee :`:1'6 7,4 A
N
Dare; pLUMBING PERMIT ISSUING FEE S (} r� ` " ' �5 Z
Signature TOiAL FEE „� � " •7 Q J��
� Plan check opplimnl a� �- ��([�,Jr(j�
SINGLE FAMILY
HOME OWNER-BWLDER DECLARATION Name �Cr,� �j�8'�
,��reby affirm�hat 1 om exempt from the Contracbr's License Address
.�..�for Ihe following reason(Section 7031.5. B�siness and
Professions Code): Ci1y Tel.Na.
❑ 1,os owner of the property,will do the work and the
strocNre is not intended or offered fot sale �Section ► ,
7044,8usiness and Professions Code).
CONSTRVCTION LENDING AGENCY
1 hereby nffirm Ihat there is a co�siruction lending a9eoty for
1he performance of the work for which this permi�is issoed
(Sac.309T,Civ.C.).
leeMB✓�W'bma . �
kender's.4dQrees
1 certlfy thal I have read rhls oppl-�co�ion and sfate thot the �
above informo�ion is correct I agree lo tomply with all County
ordinances ond State lawz regub�ing Plvmbing,and hereby
thorize repre3enrotives of ihis Coumy to entar upon ihe
o� ment' prop ty r in � tio rp�s. �
SEE REVERSE FpR El(PLANATORY LANGUAGE
Signof�re of Permittee Dafe
�r �� �� ..,s.�w` -
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f,�." � �- --� """-'—^'�"'— INSPECTOR'S NOTES p�AiNER BU�LDCR CEf.IARATION
! `_il 5 . C.TE INSPKTOR 5 SIGNATURE , . . . _�
�J�JEc 5 ..`,� . . �- —F---:'�� '• � � •" �... t��5 aso �
�"1'� 6�F-3 I here6y off��..rm that I am er.empl f om t c C n��, r r'
�40UCH F 1 t, �I - ,. ^ C ense L w for th foli ng n (5�t. 703L5.
��� 6uslness a�d Profossions Code; An cit or cour,l I
GAS r P iJ�___'_'__" ' ���' •- ' Y Y Y`^��"�
G�5 V t T , ,requires a permit to 2onsfruU,vHe impro e d mo!'rsh,
HJT\AT�R M AT �� . _ � �o repa r cpy,sfrticfure, priqr�to,�fs�tis�soantC,� Iso re-
.� . � �qu�ires fAe appliebnl4or such pt�rm I toYile'a s'gned stnie-
� '
.` .___ :�— ,
'�tU+' +��,� L" :, i'% �..F ' �" ., " .• ,� ' '; ...1 � meni thaf he is Iltansedpursuant�o the provis ons oF!hc�
-' '-� �-�� '�-���� Confractor"s License Low Cha ter 9 mmmenc�n�e�i'h
a5ie" _ �� � i P I S
�TItITv CO ^ r _ ... . . � . sions Codo-oor tfwr h,a Is exempfhfMefef�om ond�hs��is
_ '. . 'T` �� `' __ ',- 1or �he alleged exempFion Any o olaYon r Settion
� o
R�A� ('� � _}rnnf -��" ' ' � 7D3i.5 6y any opplicont/or o permi�sub�ects fh�appli-
j cant to a civi!pena�ty o�not more fhan five hundred
I V ,�•��.,- '�` - • dol�on($500).:
� � U T�I-i � , . ❑�,aa owner of th=prop�rty will do the work,ond
wA5 E F��!�i y��V �`(� . �-'—`��� • the structure is not in!ended or offered for sale. -
l�s�� . � (Sec.70M,Business and Pro�essions Code: The Cc� _
+ ' �� � "' ' . �� � �- tar's L7[ense Law doas rtot trpply to an owner ol propeNy
' . , '�. - ' ' who builds or Improves iberean, ond who does such
._.,: .. - � . ..
� �� " � � � �� . :j �\ work himself provided lhaf such improvemenfs are noi
.. • iniended or offered for safe.If,howeve�,tFre 6uifding or
' .,., , � . � improvament fs sold wlfhin one year o/compfation,fhe
!_ _ _ ownerbuilderwi/l have Vhe burden oi proving fhat be did
� nof build or improve for the purpose o1 sa(e.)
� . .. _ „ � _. ��.
I am expmp!under`Se�:. ,
`.,. _ :
. B 8 P.C+for ihis reason
Date
�....., ,��'� .
Owner
`.._______ IrJS°�CTO!;'S NOTES
