HomeMy WebLinkAbout1671A WORKER$'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm rhot I have a cer�ifimte of consenf to self 76qbp�q
. insure,or p certificote of Workers'Compensation Insurance, CE 817(REV.10/81)
or a ce�iified mpy rhe�eof c.38WSa�.� � r COUNTY OF LOS ANGELES BUILUING�AND SAFET�Y ��
POol�icy No�Com any /�t t bY� � ��
Certified copy is hereby f mished. �
� FORAPPLICANTTOfILLIN(PRINTORTYPE) � BUILDING r
Certified ropy is filed w� r i sp c ADDRESS � m/
tiondepartmenf. NUMBER F�XTUREORITEM � FEE �OCALITY �
q WATERCLOSEi � rY�Q r
Dale "�Applicant � `� J NEAREST �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRO55 ST. J Mti'G �I^ B
COMPENSATION INSURANCE SHOWER OWNER �
(This aMion need nof ba compl�tad if eho work involvad by MAIL
1h�parmN ic for one hundnd dollan(5100)or less.) � LAVATORY ADDRESS
� I certify that in�he performance af ihe work for which this
permil is issuad,�sholl nof employ any person in any manner ( SINK pa GTY� J;�� TEL.N �
, So as f0 be[ome su6jecl to�he Workers'Compensolion Laws. DISHWASHER
� �f CONTRACTOR ��,e� ,
Date Applicont CLOTHES WASHER � ADDRESS .�y�
r f""?TICE TO APPLICANT: If, after making 7his Certificate of h``"
imption, you should become subjecf to the Wo�kers' SWIMMINGVODLRtCEPiOR CITY�/_�'�{�y, /j� ,j/�
, '�,ompensafion provisions of the Labor Code,yoo musl forlh- LAWN SPRINKLER S�STEM — " Bh ro�P^' V�� �+'+!�
ith wmply with such provisions or ihis permi� shall be STATE ^J Q LIC. /�
� deemed revokefJ. ' WATER HEATER
LICENSE NO. p I O Q� CLASS v
IICENSE�CONTRAC70RS DECLARATION DiSTRICT rv0. vROce55Eo ev
1 hereby affirm-Ihal I am licensed onder provisions of Chapter9 � GASSYSTEM OUTLEiS /O �y'�
(commencing wi�h Secrion 7000)of Division 3 of fhe Business Ou7iET50VER 1''a1p n�
and Professions Code,and my licen5e is in full force and effect. 5 PER SYSTEM FINAL VALIDATION
313 0$3 G DATE � r>/� �
Litense Number Lia Class�
� �( f�Nn� ,(�j U.
Conira<for� ��r �� Date �� ��+ BY (,�/��,�'""�1�� a'
, ❑ I am exempr under Sec. �
U
B.&P.C.for this reason ' W
Plan check fee � :`.'1 6 7,1 A y'
Date: PLUMBING PERMIT 155UING FEE S Q �r a • e s .5 .Z—.
Signol�re
TOTAL FEE
I � e76,50
Plan chack applicont
SINGLE FAMILY .� �, a,J 6,5��
HOME OWNER-BUILDER DECLARATION Name
r��reby affirm iha�1 om exempt 6om ihe Controctor's Litense Address � �9'� 5���
.�v for Ihe follawing reason(Section 7031.5, Business ond
Professions Code): City Tel.No.
❑ I,as owner of the property,will do the work and the
structure is not intended or o44ered faf sale (Sedion ,
7p44,Business and Professions Code). -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construcrion lending agenry for �
�he performonca of ihe work for which this pe�mit is rssued
(Sec.3t747,Civ.C.). -
LendeYs F7amr
Lendet's lMdress �
i certify ihat I have read this opplim�ion and s�o�e ihot ihe .
above informa�ion is correct.I agree to comply with oll Couniy
ordi onces and State laws regulaling Plumbing,and hereby
aut rire represento�ives of Ihis Couoty 10 enrer opon ihe
a6 - ntione pe�� 4or ins-ectiory�q poses �
��rG�� SEE REVERSE FOR EXPLANATORV IANGUAGE
`7
ignoture of Permitlee Date
' � � � �� ����f. ��
#� - -- ��• +�n� `• +..._��a �rr
4 .� -~-t� o.T� i�JSP[CTOR59GNATURc INSPEC70R'S NpTES . - - 04tiNER 6�LD�R: I 4RAilON
�N�R 5 nF�V. ,u; �-�_�. . �'.� �: � � IJhereby ff rm,that I�m . empf f o �ihc Contrc�rar';
-.f
ROU H P l,,�?I �,�_ h � . L cense La for fha follow .g ason (5ec�ion 7031-i.
�q�p;��,r,.;�� ' ' �-''-'� •• Business ar.d Pro/essions Code):Any ci}y or county wk��r.h
_--_...—_.—___—_ —_
GAS VED T ��~� � ,`� . . requires�a permi}to ronsfrud.alfer,rmpro e d^m`olish,
��� �eri�epa r oqy strL4f.yre, prior to"1fs iqslrondAe ofso re-
��T�'�'�T� `� * —�r�� ' � 4; , quires tRe app#IM�t for wch perm�iFto fde v srgned s/a�e-
�LIP c'�L'%� ~',r -T�� . � ^ '�� . ment(hof he Is licensedpursuont io tha provi.lcns of tFe
GAS lE T 1�� ��r � Coniracfor's Llcense Law(Chnpier 9(commenciny a,i+h
y U?ILITY CO.KG 1 C�� ._. Sertion 7C00)of�ivision 3 of�he Business and Proies-
� -- — — sions Code)or thaf he rs ezempl thsrefrom and Ihe basls
� ` - � ��" � �- ior 1he alleged exemption. Any violalion of Sec�ion
�__+ t,-... -7 _
�Flhnt ..� ` � ,�`..l; r. _}mrs( ". " � �'. ' 7031.5 6y any apphcani for v parmrt subjects rhe oppli-
,��.r . .-- i �
-------=---=i--- . �� . .\ ; mnt to a civil penulfy of nof more Than fivo hundred
� t ' " `�' dollors(5500).:
'��no�...i i � .�� ❑I,as owner of the propery will do the wark,and
�wnsTe�,F*'ao��� �'�i ���-��a'� y:, `� ,�!�.;`� �� ' �he siructure Is not imended or offered for sala. - ._
��'+,:C ��� (Sec.70M,8uslness and Pro(assions Code: The Ca �:-
.�y l A...7�>� �i,;� ... .. . ` �.S,�:.5._""„_: . �
tor's Llunse Low does no1 apply to an owner of proper7y
,� . : `�'.. who builds�or improves thereon, and who does such
� � � �� �� . � work himsel(provlded that such improvements ore nol
. ,� lniended or oflered for sale.!f,howeveq the buiiding or
. -� � ��� `i - ��— lmprovemenf is sold wilbin one ysar of mmpfetion,Iha
owner•6uilderwil7 have/he burden of proving that he did
not build or Fmprove f�vr Lhe purpose of sole.J
�_.n � . , ..r''', . .
-'+: l qri axemp!under Se�. ,
`,� •�' i 1 �.
8&P.C.for this�reason
_�,
�y,
--- Date
Owner
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