HomeMy WebLinkAbout1825A WORKERS'COMPENSATION DECLARATION APPLICATI4N FOR PLUMBING PERMIT � {�
I hereby affirm that I hove o cerrificate of wnsenl to self 76q�7q ��
inw�e,or o cenifimte of Workars'Compenmtion Insurance, CE 817(REV.10�81�
or a�ertifiad copy thareof Sec.36D0,�ab.C.J COUNTY OF LOS ANGEIES BUiID G�}AND SAFETY
PQolity No����pany ��� r�C "" �- -� ���
Cer�ified copy is hareby furnished.
� FOR APPUCANT TO FILL IN(PRIN7 OR iYPE) BUIt�ING /'
Certified copy is filed wifh the couNy 6uilding insper ADDRE55 (/ r�7'7/
fiondeporlment. � jjj NUMBER � fIXTUREORITEM C2 FEE ��ALI7V
� ..�'S�j �� WATERCLOSET Q� ���
Date — / AppliGant Q r NEAREST ./� .
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRO55 ST. �
COMPENSATION INSURANCE SHOwek OWNER
(Thb��dion naad nof b�compl�hd if fba work Involv�d by
fh�p�rmif ir for on�hvndred dollon(STOD)or I�ss.) IAVATORV MAIL
I certify that In the performance of ihe wo�k for which�his ADDRESS `
permir is iasued,I shall not employ any person in any manner SINK pTY �»Q� L. 1��.
aa as ro become subject ro 1he Workera'Compensation Laws, oi5HwA5HER
� CONiRAROR � h Li�`
Dafe Applicanr CLOTHES WASHER +�
�'�TICE TO APPUCANT: It, ofter making �his Cerfifica�e of AD�RESS �
� mpfion, you should 6eaome subjact lo �ha Workers' SWIMMINGPOOLRECEPTOR
.,ompensation provisions of the Labor Code,you mu5/forth- �qWNSPRINKlER5Y5TEM CiTY j^ �n (��„ E�1�1 �.
wi�h comply with such provisions or fhis permil shall be STATE LIC. �
' deemed revoked. WATER HEA7ER IICENSE NO. . C1A55
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm-tho�I am licensed under pravisions of Chaptar 9 GAS SYSiENt OUTIETS � 1'J5 ��`O��
(commencing wi�h Section 7000)of Division 3 ot the Business pUTLET50vER '���
� and Professions Code,and my license is in full force and effect 5 PER SYSTEM FDIA�L �i�_�� VALIDATION �
ticense Numbar � 'v Lic Class� �/ 0
FINAt / V
ConiractoP�L�. e� Do�e ^ /� BY �G�.a �
I � O
I am eaempt under Sec. U
6.8P.C.for this reason �'� 8?.�j A 4
Plan check fee
Dofe: U1
PLUMBING VERMIT ISSUING FEE$ #,+� • • • �� Z
Signatu�e �
TOTAL FEE � � LL 7�5�
Plan chBck oppliqonf
SWGLE FAMILY = � �� %!�.���1�
HOME OWNER-BUILDER DECLARATION Name
��ere6y affirm fhat 1 am exempt from�be Cantroctor's license Address 0 9� �—8 7
.ew for ihe foilowing reason(Section 7037.5,Business and
Professions Code): Ci�y Tel.No.
❑ I,os owner of the property,will do fhe work and 1he
str�cture is not intended or offered for sale (Section �
7044,Business ond Professions Code).
CONSTRUCTION LENDING AGENCY
I heroby nffirm ihat ihere is o mns7ruction lending agency for
the parfwmance of the work fa�which this permit is issuad
(Sec 3041,Civ.C.).
Flad'eXs lqejme�--
Lm�de�i A�d�reaa
I certify�ho�I hove read ihis applica�ion and state rhat the �
a6ove information is correct.I agree to mmply with all Counry .
ordinances ond State lows regulating Plum6ing,and herehy
authorire repre�entatives of this Coun�y lo enrer upon�he
above-men�ioned p�operry for inspecfion purposes.
� SEE REVERSE FOR EXPLANATORY LANGUAGE
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�
Si noture of Permitlee Dote '
� � r' '�„�r"'�/�4'\ ��� � .
�� �.. �a�-�- . ��� r r.r _ � .. ..� ♦
---— �r.i i�.•�� , ..,.y
nvr��t:�����or.r> iNs��crOR�s si�NnTu�e iNSPECTOR'S NOTES . . ObVIVEP.-BUiLDER DECI.ARATIONy
uNe:e s�ns v ,nr-- --�-y(/� '2�i_ '��. ..: . . � .�. �:
I hereby affrm4hat i om e,vmp'frbm the Contr�-io�;
ROUGHFLU+":.:h':, � � ' License La•r� for the followlr.q rer.son (S�Nion 7G31.i.
GAS C V:; __� f - �±,�� � � Business ard Protessron�Code!:Any uty or ou ty�wh�ch
GAS VJd7 � ' f � �� � requires a permn fo constrvct,alter impro d_molish.
HOT W'ATER HEAiEF .I . , or repmr�ony sirucfure, prior to 7fs asuancc, also re-
-quires ihe o'ppliconfior sach permrt to f le o s'gned sfa�e-
P�UMB:NG:x U .� � �� T- �� ' � ' � � � � ment tFvt he a hwrtsed pursuant to the prov'rsions oF ihe
GASTEST � ' � � Conlracior's Llcertse Law jChcoinr 9(commencing.�-ith
UTILITY CO.NO?Iti'_�� �I __ Section 7000j a(Division 3 of Ihe Business and Profes-
--�-----. zions Coda)cr ihaf he is exempf Iherefrom and Ihe bosis
� ~ ...j �� � � � for ihe alleged exernption_ Ar,y viololion of Secnon
.—_.__�_-____, .___ on:7
f�^�A�` _ ,(r.f.r }mref ' � - � � 703i.5 by ony applicani for o parmif subjeds fh^oppli-
— - --- , cant to a civi!pe�affy o/not more than iive Rundred
' ' . ` . - dollan(5500).:
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'v� ST . � - � ❑I,as owner cf fhe property will do Ihe work ond
`ti4 i _Py vFt_ � � —T" � �'"""�' ihe structure is not intended or offered for sale.
, � _ � (Sec.70M.Buslness and Pro/essions Code: ihe C¢ } .
- . � �- � "- � � � � � ior's Licanse Caw doss not apply to an ownar of proNdrty
- � . . � . � � who buflds or lmproves Ihereon, and who does such
� � � � � � wotk himself provldad}haf suth impravements are no�
' ' intended or offered for sale.If,however,fhe bulfding or
. �� � � , improvement!s sofd wilh�n one ysar of mmplerron, ihe
� � owner-bW7der will have}he 6urden of proving�hol he did
nof budd or improve for the purpose of sale.)
(am exemp!under Sec.
- B&P.C.for ihis reason
Date
Owaer
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� b`�'S?cCTO�'S NOTES