HomeMy WebLinkAbout1838A ,WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT . �
I here6y offi�m ihat I have a cenificote of consent to self 76A667A
t�sure,or a ceNifimte of Workers'Compensalion Insuronce, CE 817(REV.10/81) �
a�o certif�ie+d�mppy�(t�hereof(�S,e^c.3600,Lab.C.) COUN7Y OF LQS ANGELES BUILDIN,Gp¢AND SAFETY j�
P❑olicy No{1_/__Q.�JZLCoIlip�ny ���`f° ��� 'Ff� p �3(/
Certified mpy is hereby ivmished.
� FORAPPtICANTTOFlLIM(PRWTORTYPE) BU�IDING / /
Ceriified copy is filed wilh the county building inspec- aDDRE55 (�J
f'on depwlm t. NUMBER FIXTURE OR ITEM (� F�E �OCAUTY �
� WATER CLOSET
Date ��� Applicant��s��'e✓ ����^ NEARE57
CERTIFICATE OF E}(EMPfION fROM WORKERS' �J, BATHTUB CROSS ST.
COMPENSATION INSURANCE OWNFR
(This aedion noed not b�complefed if fha work involvad by SHOWER
MAIL
tho pormif i�for ons hundrod dollan(S100)or I�ss.) LAVAiORV qDDRESS
I cer�ify that'n Ihe performance of the work for which this
parmit is issuad,I shall nof employ ony person in any monner SINK GTY � T . O �,�
so as to become subjec�to fhe Workers'Compensotion laws. DISHWASNER
CONTRACTOR � ��
Dale Applicont CIOTHES WASHER qpDRE55
/"�TICE TO APPLICANT: If, afler making this Cortificale of SWIMMINGPDOLRECEPTOR
� mption, you should become subject ro the Workers' �
l.ompensation provi5ions of the Labor Code,you must forth- �qy,�NSPRINKLER SYSTEM CIi1' -�h v� t a
wifh comply wilh such provisions or fhis permii sholl be STATE . LIC.
deemed revoked. � WATEk HEATER UCENSE NO. Q CLASS
LICENSED CONTRACTORS DECLARA710N �IS7RICi NO. PROCESSE�BV
I heraby offirm�hot I am licensed under provisions o4 Chapter 9 GAS SYSTEM OUTLETS �Q �����
(commencing with Seciion 7000)of Division 3 of�he Business OUTtET50VER
and Professions Code,and my license is in full force ond effect. 5 aEe 5v5TEM iINAL ,�-�-�/��/ VALIDATION �
license Number ��✓� a � Lic.Closs�� OATE �j O
� i
� �{ � ��/��Z'"7 FINAL i U.
� S__LL�1..�_ BY ��rr�`�'G �
Controctor �6�Date z n O
I � I am ezempt under Sec. �<.�.� E�.C A. U
B.&P.C.for ihis reason ��� Q �5 W
Pian check fee � �+� � ° p.,,
Date: p�UMBING PERMIT ISSUWG PEE'$ � �:. ����,5O Z
Signature ��
TOTAL FEE �f s . , i,c c;J�
Plan check appliconl
SINGIE FAMItY fl C�.� 1`��7
HOME OWNER-BUILDER DECLARATION Name
��areby affirm tha�I am exempt from the Contractor's License
.aw for the following reoson �Section 7031.5, Business o�d Add�ess .
Professions Code): City Tel.No.
❑ I,as awner of the property,will do fha work and fhe
svucture is not inrended w offered foi sale (Secrion ,
7044,Business and Professlons Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm thct fhere is a consiruction lending agency for -
fie perfo�mance of ihe work for which this permit is iss�ed �
(Sec.3099,Civ.C.}. '
t�rta�+r Rtnnc
ka�rcters Rddoess
I certi£y tho�I hove read this opplimtion ond s�ale that ihe �
a6ave infarmotion is correct.I ogree to comply with oll County
ordinonces ond State lows reguloting Plumbing,and here6y
authorize repre�entatives of Ihis County to enter upon ihe
a6ove-mentioned propertyforinspection p�rposes.
���������II` SEE REVERSE POR EXPLANATORY LAN6UAGE
Signature of Parmittee pate
�_""" ."" INSP€CTOR'SNOTES ��� 04VNE2-BUILDCRDFCI.ARATION
A'�':" . ��CATE INSPEC'OR'SSIC>NATURE - . ,�
uNOER,.���d�JE ���fJ� ' I�hera6y�offirm�rFar I om exe pt 1rom'rne�Cnntrc��o�s
RCI.CN-_Uh��';� � � � � license Law for !hc� following .ason (Se�hnn 7031..5,
GASFIF��.'vid _ _ _/'$1`�/ I� � - _ _ BusinessondFrolessionsCode).Anycityorcounlyw�i�ch
�-- requires a permif ro cons�ruct,a(�x,improve,d=molish.
GAS VEI'��T � - . „
� � ,i� '��or�epair ony slrocfure, Prior fo ifs issuance, also re-
NOT VlATER t 7'S � uires'fh'e a i cant for such ermif ho file a si ned st�to-
F--_- : � . 4 PP' P 9
�UM9,1�ci f .� � � � ' � �� • ' - - menf fhv�he is litensed pursuont�o fhe prov�sicns ol�he
GA51 � $'� 4""����-- Cqntrattor's Li[ense Law(Chopler 9(comme�cing�•.ith
�UTI�I7IC^,.M1pIIF-�� Secfion 7000)ol Divisron 3 of fhe 6usfness ond Pro�es� �
7 � --- ---�-- , � � sions Gode)or thot he is eaempt fbarefrom ond the bosis
1 __ I � � lor the afleged exa.*mptlon. Any viofalion oi Seclion
i p�,r:q; � � �r' c7 . � 7031.5 by any opplicaM for o permit subjecrs>h�appli-
______ . _frr on J�onE� cdnt to o civi!penalty of nnf mare ihan tive hundred
doUars($500).:
INWSTEI:.i � . ' . ❑I,as owner c`the praperty will do the work,and
N.�as�F P�FFn[�'=a! . � � . � — � -�� ihe structure is noi intended or offered for sale. "� .
. '������ �� � '� (Ser.704�,Buslness ond Profassions Code: The Cc .-
- - � � - • � tor's llcense Law dox not opply to on owner of property
. .� � who bWlds or improves ihereon, ond who does sucb
�� � � � � � � � wa�k hrmseli provlded lhot wtB improvemenis are not
. . . � irttended or o(fared lor sale.If,however,the building o��
. � . . . , . improvemen�Is so/d wi�hin one year o/completion,fhe
� owner-buildorwill have fbe burden of proving�hat he did
� noi buifd or improve ior the pu�pase o!sale.)
�.
� I am exemp!under Sec. ,
B&P.C.for ihis reason �
Date—
Owner
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