HomeMy WebLinkAbout1823A � $ATION DECIARATION APPLICATION FOR PLUMBING PERMIT {�
I here6y affirm �ho7 I have o cerfificate of conseM fo self 7pq�7q ��
insure,or a certifimfe of Workers'Compensotion Ins�rance, CE 817(REV.10/61)
or a cerlified topy ereof��3800,Lab�.C/.�� COUNTY OF LOS ANGElES BUIIDING AN�SAFETY
P�olicy Plo`j��Company.�Lll; �� '� � �
Certifiad copy is hereby furnished.
� FOR APPLICANi TO FIIL M(PRINi OR TY7E) bUIIDING /
Certified copy is(iled wifh ihe couMy bvilding inspec- ADDRE55
fion depar7menf. N�MBER FlXTUREOR ITEM @ FEE �pCAUTV 8 �--
Dare ��.L�L_Appli5anl � �-� � � WATERCtOSET 4 NEARE57 ,^ M
CERTIFICATE OF EXEMPTIQN FROM WORKERS' �..-
9ATH TUB CRO55 ST. /�� CC.
COMPENSATION INSUI2ANCE SHOWER OWNER
(Thts��c8on n��d not b�compl�fvd!f tbo wo`Fc Inrolvod by MAiI
ih�p�rmif ly for on�bundr�d doifort(5100)or 1���.) LqVAiORv ADDRE55
I certify that in the perfo�mance of the work for which ihis
permit is Iss�ed,I sholl not employ ony person in pny mpnner SINK CIN � TEt.N
eo as to bemme su6jec�ro fhe Workers'Compensofion tows. DISHWASHER �
CONTRAC70R �j � �er
Date Applicant CLO7HE5 WASHER A�DRE55
�d�-'qTICE TO APPLICANT; If, affer making this Cerfifimfe of SWIMMINGPOOIRECfPiOR O
; mption, you should become evbjett to ihe Workers' CITM
..�mpensalion provisions of 7he Labor Code,you must 4orth- LqWN S�RINKIER SYStEM � � � 'Q'
wiih comply with such provisions or Ihis permit shall be STATE ] LIC.
deemed revoked. . WATER HEATE2 LICENSE NO. . / CLA55
IICENSED CONTRACTORS DECLARATION DISTRICT NO. vROCESSeD BY
I heraby affirm rhat I am licensod under provisions of Chapter 9 � GAS SYSTEM OUTtETS /T K'�1 0. ��
(commencing with Saction 7000)of Division 3 of Iha Business OUilEi50VER
Lf 1 '\
and Profeulons Code,and my licanse is in full force and effecL 5 PER SYSiEM FINAI
� � �/�-7' VALIDATION y;
(/' DATE h � �'' �
licanse Number � � D S 3 Lia Class_,�.� � p
P �i��] FINAI ��T��.«.,.�1 U
Conhocfor 1 C�'Q� po}e�-�� BY '" �
� � O
�om exempt�nder Sec ��'1 S 2 3 A U
B.SP.C.for�his reoson W
Plan check fee �� o � o �� p.
Date: PLUM8ING PERMI7155UING FEE 5 Z
Signatwe l 4 ��b,J��
i07ALFEE
Plan check applicant � �' ¢ r��n J
SINGIE FAMItY (�Q� %-�&7
HOME OWNER-BUILDER DECLARA710N Nome
C�ereby o4firm�hat I am exemp�from the Con�racrols 4icenx Address
w for the fallowing�eason(Section 7D31.5, Business and
Professions Code): Ciry Tel.No.
❑ I,as owner of ihe property,will do ihe work ond�he -
structure is not Intended or offiered fof sala(SeUion �
7044,Business and Professions Code).
CONSTRUCTION LENDIN6 AGENCY
I here6y affirm thot there is a mnslruction lending agency tor
the perfamance of ihe work for which this permit is issued
(Sec.3097,Civ.C.).
kae�r/sA� —
Lender's Addrms
I certify tho�I have read�his application and uate�hat the ,
above informotion is correcr.i o9ree ro mmply with all Counry
ordinances and Staie laws regulating Plum6ing,and hereby
aothorize representatives of this County to enher upon fhe
above-mem�oned properry fo�inspection p�rposes. �
n „��rn' a SEE REVERSE FOR EXPLANATORY LANGUAGE
�t oi� /"���� ��J
Signature of Perminee Date
_ __ __ _ __ . . -
..�� , _ ,_ X � -- �`- ����
� ; i�ls! �.+�rr�� *�r!,►
��i ��
- � INSPECTOR'S NOTES O�hiIJE?-pUILDFR DFCL4RATIqN
l,Pf{:nl'?.!,Sv��—�i_-_CAT� !NSPECTOR'SSIGtJATURE ' .
UNCERSL e O^.e � .I�j / ,��'7 � � ' - I�hereby offlrm rhat I om e empt from�Ih Cenv�ctcr',
RpU�HF;.Uh'�,31K;� � License Law for the followi.g renson (Ser.tion :0915,
GAS F'�P��N __ �_ �-I � ,_J��l.. � � � _ Business ond Prolessron5 Code!:Any dty ar covnry wh oh
GAS VE�. �, � requires a permif to canstrud al}x improve,demol sh.
-�of repair ony sfru6ture, prior to�/s iqsuance, also re
HOT wA7E F n'[k {I � - �quires the appffcanf for sucA permit to file a s'gned srn+e-
�Plt;nl��.Nc Flx`F,.ts 7 � � - � meni lhet he is licensedpursuonf fo 7he provis c�s oi tFe
GAS iE5 � � j��jr� � � . Confracfor's License low{Cho,otcN 9(commencing���i'h
UTILITY C0.KOTi�I[D j � __ Secfion 7D00J of Oivision 3 01 Fhe Buslness and Profes-
----- � � sions CodeJ or fhaf fie is exempt tberefrom ortd tbe basis
I
___.___._ ,___._.._i.._._.__�__c7 _.'_ . - for the alfeged exnmption. Any viofolion oi� Sac�ion
F��A� �' rf e;frr an _/roa( � 703i.5 by ony apphcont for a permit subjacts ike appli-
------------ . � cant to o civi!panalty of not more fhan five hundred
.` . � :. . � daifors(3500).:
Y —______-.---.�--------_.—
g iND�iS'a'.Ai � � ❑I,as owner o`.ihe proparty�Nill do the wark,nnd
P J�'ASTc n�i zOVA,� � �� � '� .- Ihe sfructure is not imended or offered for sole_
� � � ��� - (Sec.70M.BusinessondPro/eesionsCode: T6eCc ~.
,. . ' ' . � � . . � � � tor s Lleanse Low does not apply fa on owner of proN,:ny
� , �- . . � who buifds or improves ihereon, ond who does such
' ' - � - � - work hlmself providrd fhat such improvemenfs ara nol
� � frtfandad or offarad fbr sole.!(,howaver,the 6uHding or
. � , . . � improvement ls sold wHhin one year o/comple}ion,ihe
owner-buiiderwllf bave the burden o!prov�ng thaf he d�d
. not butld or Improve for tha purpose of sole.l
I am exemp'under Sac. � ,
- B 8 P.C.for ihirreason
Dore
Ownec
^ ItdSF=CTOR"S NOTES