HomeMy WebLinkAbout1824A 'COMPENSRTIOM DECLARATION qppLICATION FQR PLUMBING PERMIT {�
I hereby of{irm tho� I have a certifimte of tonsent fo self 76A66�q
knsure,or a cerriflcate of Workers'Compensation Insu�once, CE eV IREV.ID/BI) • U
or a cerrified mpy rhereof(^S�ec.3BOE7,Lab.C. n COUNTY OF LOS ANGELES BUILDING ANlD SAFE7Y � `../
Q�r N����orS,Pany C� t�Vn� !'��. �' .G � �—rJ 1 ''�
Certified copy is hereby furnished.
� FOR APPLICANT TO FILL IN(PRINT OR TYPE� BUILDING ^J �
Cerrified copy is filed wilh Ihe counfy building insper ADDRE55 � /r /"'
Da�e�1' n depariment. NUMBER FIXTURE OR ITEM @ FEE ��A�ITY
�Applicanl , � WATERCLOSET NEAREST / �
CERTIFICATE OF EX€MPTIQN FROM WORIfERS'
flATH TUB CRO55 ST. `LZ� /
COMPENSATION INSURANCE SHOWER OWNpR n ,� .
(This seclien ne�d mf ba complaf�d ff-1h�work Inw4v�d by ��i
}hw p�rmit t�for on�hundnd dollan(f100)or I�ss.) LAVATORY ADDRESS
I certify�hal in�he performance of the work for which this �
permii is issued,1 shall nof employ pny parson in any manner SINK CIiY O r� �� EL NO. � �
So os to become subjecf fo the Workers Compensafion Laws. Di5HWA5HFR
CONTRACTOR
Daie Applicanl CLOTHES WASHER qpDRESS fi —�¢
�/"�TICE TO APP�ICANT: If, ofler making this Ceilificale of SWIMMINGFOOLRECEPiOR
mption, you should become wbject ro th� Workers'
CITY
l,ompensation provision5 of the Labor Code,y0u mu5f forlh- �,q�+/N SVRINKLERSYSTEM u� � ���'�
� with mmply wilh zuch provisions or Ihis permif shall be STATE IIC. �a
deemed revoked. WATER HEATER UCENSE NO. � � CLA55 �r
IICENSED CONTRACTORS DECLARATION DISiRICi NO. PROCESSED BY
i heraby affirm thpt I om licensed under provisions of Chapter 4 GAS SYS7EM OUTLETS //'1 �Y�h qq O� �
(commencing with Section 7000J of Division 3 of the Business OUitET50VER �
C.i \ �\ 1
and Vrofessions Code,and my license is in full force ond effecl. 5 PER SYSTEM FINAL VALIDATION
LicenseNumber 3/3aSs3 licCloss_��_ DATE „��� � Q
FINAL �)/ � U.
Contrac�ar '� � •�ate� l� gY rl�C/ "` �.
� ❑ I am exempt undar Sec. ;;� �2 2(J F U
B.&P.C.for�his reoson .� � W
Pian check fee ► „ � � • _ •� d
Dofe; p�UMBING PERMIT ISSUING FEE S + ,- r']�S Q Z.
Signafure
TOTALFEE 7�S��
o ,. _
SINGLE FAMIIV P�an check applicanl Q� .� .��fi 7
r...., HOME OWNER-BUILDER DECLARATION Name
areby affirm�hat 1 am e.empt from the Contracror's ticense Address
_.�w io�the following reason (Section 7031.5, 6usiness and
Professions Code): Ciry Tel.No.
❑ I,as owner of ihe property,will do the work and the S
structure is not iMended or offered for sale (Section
7044,Business ond Professions Code).
COMSTRUCTION LENDING AGENCV
i hereby nffirm fhat fhere is a construc�ion lending agency for
�he performance of ihe work for which this permit is issuad -
. (Sec.3094,Civ.C.).
k�d�.�+s Nae�n. —
kerrdan s Rddiees �
I certify thot I hove read�his opplim�ion and state�hat ihe �
obove informotion is mrrect.I agree lo comply with all Counly
ordinonces and Srofe laws regula�ing Plumbing,and here6y
ou�horize rep�e�en�n+ives of+his Coun�y �o e�1e� opo��he
above-mantioned property for inspectlon purposes.
SEE REVERSE FOR EXPIANATORY LANGUAGE
S,C�,�� " ��C Q'/�
Dofe
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�.P �' s �4,�c{Are iN5aec7oR'S StGt�lAruRe INSRECTOR'S NOTES . 04�iNER BUILDCR D rl qRAT,ION
I.N�ER LA�.�� p..�/ �'-.+ l.��-; . .
�t 7� I hereby offirm that I am exempr{,om tne Con r�ir,�';
ROJ H?WeA�� ,� _�y, � License Lav� for the 4ollow�ng e son !Sec .n i0J�.5.
�S F F�'- —L �"'��' ' �O� ' 8 siness and Profession�Code).Any<ty or o fy-`�ch
CS V PT ( � requires a permd to mnsfru4 alfer,�mpro E d I 6.
HOT N A7E�.-f 1TL � � . � �.oF-.t'epoir ony struVure, pr or to Ils lssuoncc�ol o re-
_,�_. � quires ihe applitant lor such pe�m f b tile o signed ct te�
FlUM146�.tJ.;-l.:ii��4E:, � - � - � - � � meM fhot he fs Hcensedpursuont lo the prov'�sions of the
GAS 1ES� � Canfractor's Lfcense Law(Chopter 9(co ing�•,ifh
UTiliTv CC.�tiCil�'.�o � � _ Sec�ion 7000)of Division 3 of ihe Business ond Profes-
� -� sians Code)or ihat Re is ezampf tMerefram ond ifie bcsis
—�—�-���..`..�.'_.. —� " . . 9 P Y violalion ot Seclion
! � ior fhe alle ed exem ilan. An
Flr:.0 . r' ^/ . � . . � • 703L5 6y eny appUcant for p permi�sub�ects rh=appli-
__ � �r.L-v on ,ir��nl cant to a tivi!penalty of nat more fhon five hundred
dotlors(5500).:
�INDUS LIAt . � . . � � ❑I,as owner cf the property will do the work,qnd
��.a T %!4 ihe structure is not intended or offerad for sale.
--J����� � , � � , (Sec.7044,Busins�s ondProfessions Code: The Cc^c
.. , � - ' � � �- �� • ' � � for's[Itenae Low does nof opply fo an owner o(propeny
� .�. who bullds or improves thereon, and who does such
' �� � . work himself provlded fhot such improvemenfs are no�
� � intended or offered for sale.If,however,the buifding or
� . . � � � .. � - , improvement!s sofd wifhin one y�ar of complefion,fhe
owner-6uifder wiff fia�e tFe 6urden of proving tho�he did
��� ^ not bulfd or tmprove for tha purpose of sale.)
t am exemp'under Sec. ,
B&P.C.for this reason
� � Dvte
Owner
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