HomeMy WebLinkAbout1670A �� MPEN3ATIOIV DECLARATION qppLICATION FOR PLUMBING PERMIT -�{
I hereby afflrm 7hnt I hove o certiflcoie of consenl lo self �yqyy�q
, insure,or a certificote of Workers'Compensation Insuronce, CE 8V(REV.10/el) . U
or o cerr�t�ied�co�jpy�j t�hereo�f(Se.3800,La,6j.,C.}.},,,, COUNTY OF l05 ANGELES 6UILUING AND SAPETY �/
P�olicY No.VJ[�y217'�'Com�arl �. 1 G✓c '�� fi•K.�/ � ^'W ��
Cenified copy is hereby f nished.
� FpR APPLICANT TO FIU IN(PRINT OR TYPE) BUILDING /� � i
Cer�ified copy is filed wif n m�r s A��RE55 Y.!
ti n de ortmen�. � NUMBER GI%TURE OR IT�M rCc FEE *
LOCALfTY �a�/^
Date ��ApPlicont ( l�. � �, WATGRCLOSE7 NEAREST / +� �1� ��
CERTIFICATE OF EXEMPTIQN FROM WORKERS' BA7H TU6 p� GRO55 ST.
COMPENSATION INSURANCE OWNER
(Thfs�atfion r�,wd noi be campl�fad if Th�work Involved by SHpWER Y>
fhe parmit is for ons hundr�d dellen(5100)or Iws.) lnVnTOev MA�t
ADDRE55
I certify that in Ihe performance of Ihe work for which this '—'
permit is issued,I shall not employ ony person in any manner SiNK �a OiY�v; TEt.N .
so as ro 6ecome subjetl to the Workers'Compensa7ion Laws. I DISHWASHER Oa 1
� CONTRACTOR � Q �
�Do�e opplicOnt CLOThIES WASNER Q ADD2ESS 1 ,,,,(�
�i"�TICE TO APPIICANT: �f, ofter moking �his Ceriificote ot di J�A. {�1
mplion, you should become subject to the Wo�kers' 5WIMMINGPOpIRECEP70R /�I I /�.+r /
� �ompensation provisions of rhe Labor Code,you m�st forrh- LaWNSPRMKtER5VS7EM CITy�Q`"�'$ `-��VQ' T '
with mmply w'1h such provisians or this pe�mil sholl be STA7E LiG ��
deemed�evoked. WATER HEATER LICENSE NO. � d C1A55
LICENSED CONTRACTORS DECLARAiION DIST21Ci NO. PROCESSE�BY
I hereby aHirm 1ha7 1 om licensed under provisions of Chapfer 9 GAS SYSTEM OVTLET$ /1/�^� rn 1
commencin with Section 7000 of pivision 3 of the Business dU '"`�"OnG
( 9 ) pU71E750VER
� pnd Professions Code,and my license is in full force and effetf. 5 PER SYSTEM fINAL
(� 2[J- DA7E � �-' :�� VALIDATfON �
License Num6er ��� Lic.Class�S1� n'
('�� _ Q� FINAL l
Controctor�"��� r � �ate -` '�� BY �%/'��,.y.-t�'"L �.
❑ �
I I am exemp�under Sec. . �,:� L 7 Q a O
B.&P,C.for�his reason � - W
Plan check fee ► $�`o • • • •5 a
Dare: PWMBING PERMIT ISSUING FEE$ Q I � •�I Q S O �
Signature � •
TOTAL FEE �• �+ .,%�.S(i c=.� �
Glon check applicant ��
SINGLE FAMILY [t 9,1 � 8 7
HOME OWNER-BUILDER DECLARATIQN Nome
'�re6y af4irm thot I om exempf from the Contracfor's ticense Address
«for ehe following.�son(Section 7031.5,Bvsiness and
Professions Code�: City iel.No.
. ❑ I,os owner of the proparty,will do the work and the
� structure is not infended or offered for snle(Seciion ►
7044,Business and Professions Code).
CONSTRUCTION LENDWG AGENCY -
� I hereby nffirm Ihaf thare is a conslruclion lending agency fo�
� the performonce of fhe work for which this permit is issued
(Sec.3047,Civ.C.). �
Lemd�'s�� -
lendar�'s Rd�ma --
I certify�hot I have read�his applicafion and sfate that�he ,
abave information is carrecl.I ogree ta comply wilh oll Caunty
' ordinances and S�ate Iaws�egulating GI�m6ing,and hereby
fhorize represenla�ives of this Counly to e ter upon the
�bo. -manlio property for inspe fion rpose�
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signoture of Perminee Date
. .+�+1�i'+ .�i�14i�Ml�J� ��7� M�l�A3Ll�i#
�NSPFCTOR'S Np7E5 O��fNE2-BI 1II,DLR DECIARA7ION
1.R � DA'F. INSPEC�OR'S SIGNATl1RE � ., �; ...Z .; Y � , ; , , ,,,
) 1 `
11NC R ..."F�� i. �.r�! �/. ��' � ' ��� i hereby aff'irm thot'I o exempT fiom�ih�Con�rccie�s
a��sH ri��f , �Q'•�__-_•_ � u�e„se ��v, fo� rF.� toi�ow��g �easo� �s��no„ �osi s.
�l._
GAS F��PIN� � ��j�� � �" �� ' . �usiness ond Pro(essions Code):Any cily or<oun+y�yh�ch
— requ'rres a permff to construct,oher Improve d_mo�sti.
Gt.S VEhT : > � ;� . . . ..
�.ur repai�ony sl(�ucJure prior fa�ts i�sJop b olso r
HOT1U`T. !I �r� � . ,�_ . ... ' � `� �{ quiresfheap'p�lic5nf�/orsuchperm.�/}o(ileoslgnedsfnte�
+ t
FLUn„ ;f l � # '�i ` �" '�— � 4� " men!fho�he iz licer,sedpursoont to Ihe pravrsrons o�fhe
Gas i[�� ; � Contractor's Licertse Law jCho,oter 9(commenc�ng+•�'h
" Sacfion 7000J o/Ofvisfon 3 0l thr Bus{ness and Pro�es-
� � � i � ^
�Uliuiv CO.n:CiiF�,ED I ' ,.. .. ,� sions Code)or fhaf fie is exempt therelram crtd the basis
� •. - cy �- �� '� for the alfeged excmptlon. Any violation of Secfion
�F�''�� ����� °('+ f n _7�roa1 �''�%� i ' � ' . 703i.5 by ony applicant for o permif so6�ecis the appli-
�-- , „ , cant to a ciWf panaffy of not more�hon (ive hundred
M� � =� ���,. ���6-r � . dolfars(5500).:
91ND :�.I^. �i , . �i �,�� � ❑I,os owner cf Ihe property will do�he work,and
9��HS�.,;c,.E�� . ' ; r � i .�i ` the stroctura is not intended or offered for sale.
a �_. k:_ ' � -
� ���-�1� ' - (Sec.70MF,Bas'rness end P�olessions Gode: ihe Ce 'r
'�..r.'Y � � , , , . ,�. i.'_ —
�� � , tor's Llcsnse Low does not opply to an owne�of property
.f + � who 6ailds or Improves ihareon, and who does such
� `��� ��� � ' -''� � '�� . ' '� work himself p�ovlded thot suth improvements are no�
. _ � infended or offered for svle.N,howeve�,ihe 6ullding or
. ' ,.., . � � w , improvemenf is sald wilhin one ysar af completion,rhe
, owner-bWlder wil!have tAe 6urden olproving that he did
� ��_ no+build or improva..for tf�e purpose of sale.) ,
.,
_'::.; i ...,
�� ,�y 4 Pm Sxamp!under'S�c.—
, . . a .. , ,
. � B&P.C.for ihi5'repson
� ' ' �'� Dale--
.1
Owner
^ a�JS":.CTO^i 5 NOTES