HomeMy WebLinkAbout1682A � APPLICATION FOI� PLUMBING PERMIT
ERS'COMPENSATION DECLARATION f'�
I hereby aftirm ihat I have a certifica�e ot consenr to self �yq��q � `I t
insure,or a cer�ificafe of Workers'Compensatian Insuronce, CE 8A(REV.10/81) �
' o�a certified mpy thereof 3800,lob.C� COUNTY OP l05 ANGELES BUI IN AND SAPETY LJ
O�Y N� sa ����Y � ,n�..c�'� '� zs8d 1-b/ �z.
Certified topy is hereby nis ed.
� iOR APFLICANTTO FILL IN(7RINTOR TVPE) BUILDING b r i �
Cerfified copy is filed w� i u i s ADPRESS
Date�ti n deparfinenl. � NUMBER FIXTURE OR ITEM [q1 fEE ��A�ITV ' R
/y�7APPli4ant G � WATERCLOSET W NEAREST ,a�� R.7A�Y�'
CERTIFICATE OF EXEMPTIpN FROM WORKERS' BATH iUB CRO55 5T. O G� YY�O V '
COMPENSATION INSURANCE SHOWER OWNER ��„` �
(Thls seclion nwd no+ba complatod if The work tnvolved Ny MA��
the pmrmi�i�for one hvndr�d dallors(5100)or b�s.) tqvq70Rv AODeE55
I certify�hat in the performance of�he work for which�his �,r/
permif is issued,I shall nol employ any person in any manner SINK (,O CiTY CQ� TEL.NO. y
so as ro become s�bjecr ro�he Workers'Compensation laws. ! DISHWASHER �
�� CONTRACTOR
Dale Applimnf CLOTHESWASHER ADDRE55 +
,,.A+OTICE TO APPLICANT:,If, after making this Certifimte of �1 �1'�- 16
mpt�on, you shoutd become sobjetl fo the Workers' SWIMMINGPOOLRECEPTOR
_.,mpenwtion provisions of the Labor Code,you musT forfh- LqWN SPRINKLER SYSTEM ��TY� ,�h �J�, � �.�
with comply with such provisions or this permit shall be S1ATE IIC, i+
deamed r�voked. WA7ER HEATER LICENSE NO. CLA55 �.i
LICENSED CONiRAC70RS DECLARATION DiSiRiCr No. P CESSeD Bv
I hereby affirm Ihpf I am�icensed under provisiona of Chapter 9 GAS SYSTEM OUTlETS /J�. T11 a��n
(mmmencing with Secrion 70W)ot Division 3 of�he Business OUriETSOVER �� � � �
'� and Fofessions Code,ond my licensa is in f�ll force and effact. 5 PER SYSTEM FINAL
�,���Q�? DATE �f /3��u VALIDATION �
License Nomber_L1=�.S�LSTS.�Lic.Class�'��
"� FINAI �' U.
Contractor ���� Date '� � BY ���i'°"�"� �
I � O
� I am exempt unde*Sec.
B.BP.C.for ihis reason :-� G�5 2 A W
Plan check fee a,
Date: '- e • e
o�
PLUMBING PERMIT ISSUING FEE$ Q �' � Z
Signptu�e
TOTAL FEE � ` ����5�
Plon check applicani a - . ..,';.Jr t)� �
$INGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name � O G',� rJ`S 7
��reby af4irm thot I am exempt from the Coniracror's License qddress
.,�for the followi�g reason(Secfion 7031,5, 8usiness and
Professions Code): City iel.No.
❑ I,as owner of the p�operty,will do the work and fhe
atruaure is noi intended or offered 4or sale (Section �
7044,Business ond Crofessions Code).
CONSTRUCTION LENDING AGENCY .
I hereby affirm ihpf fhere is a consfruction lending pgenCy for
the performanca of the work for which�his permit is issued
(Sx.3097,Civ.C.J. -
herdgXa�
Land�'s's Rdttrms —
I ceriify rhot I hove read this applica�ion and stote that the ►
above intormation is correcl.1 ogree�o comply with oll Couniy
rdinonces and State�aws reguloting Plumbing,ond hereby
thorize representa�ives of Ihis County to enter upan the
0 ov enfi � per fo syyyqqqc���ppp pu ses.
� ��n��/��•� SEE REVERSE FOR EXPLANATORY IANGUAGE
7
Signat�re of PermiBee Da�e
,. 1�� �0�11M�'l�A�11�i ...•�...,�..w.. ...�
—- � ... .f•.*....... , ..V�/h .
��.] W• 1 f M�
...._____._.._�.. WSPECTOR'S NOTES ' . O�A/NER$UIL�ER DECI_4RAiICN �
A=f'�L .. ,,,y D'iC INS?£CiOR'SSIGNATLIRE ��� �.�� . : ,. - ,.. ,. � -..
UNOFR� IAF Na'�,K�� �y ."G �, y �� I h by 14't�i�af I e pf,f I P CD t. .f �'-
ROUGH?'Ut a� � � y�� � Lce se L v f �rhe f Ilo ' g a n (S: I r 703L5�
AS F Fm. i � ' � B s nes d P (es C d �Any c fy o ly f�rh
.. jj i_
_ .�;� ._ _— _ _._—._._, •
Gn5 VEN� • . . . r^. ; •�requires�apermi��o.c n+ruct,ober improve d=moRsS.
_� . . .i .- . ,„. ., ,
HOT WATER H a7�'� � . . ; ��o{rBpnv any s.J�urlu , pnorfo��ts jsfuv � �also re-
i ��f__'.....�T- ^: '� ' �• --• L...., 9wres fhe app(MAn6ior su<h perrP�1 fo kleb gned s�a�e�
PLi�+nsi�a3�ti � �" � ` - ' �' x- � menf thef he is licensed punuant fo fhe pro isions of fhe
GAS TES' � Coniractor's Llcense Law!Chopfer 9(cpmmencing��.r^h
UTILITY CC.�O'"IFI[D I Sxiion 7000)of Division 3 of fhe Business ond Profes-
� sions Code)cr ihot fie s nxemp�tM1are/rom cnd ihe bosis
� ��y� � i��� '� � ' for lhe afleged exernptlon. Any violonon of Seuion
t - �7 — 7031.5 b an a Imant for❑ ermit su6 cis fh_ I�
v��nAt �i t � �(,4 f nn�_t�naf �,� �'.r -•.• .��' �. Y Y PP P le "�PP�.
cont ro a civif penalty o!not more tMon liva hundred
— — � 1�'��f _ 1 .. dollars($500).:
INDUST✓I4'e � � ❑I,aa owner qf fhe properiy will do ihe wark,and
u�`����^�F > "' i^��� � — �- —�—" � �he sfructure is not infended or offered for sale.
.�t � �(� . (Sec.7D4t,Busir»ss andPro#essians Code: ihe Ct � :-
..>. �..`d�." ,�,:.*� ; ...�o�i .� 1 "��r�.'.. ��----`- tor's Lleensa Law daes nof apply to on awner af pror-��}Y
, � ., , � who builds or Improves therean, and who daes such
�-"`' �-� - �• ' �� �- ., � work hfmself provided thot such improvements ore not
lntended or offered for safa.lf,however,the 6ullding or
' _;. , ..r ., ,. � improvement h sold within one year of completion.ihe
owner•butlder wilf have�he burden of proving fhm he did
� ^ rrof build or tmprove lar the purpose of sola.)
�...1.prrLe�emp!under Se�. ,
, l'�'`� ''' :�".'
8$P.C.for thi�Sr9ason
Date
Owner
—_—._�__,_.i:'S^cC?OR,'S NOTES � .