HomeMy WebLinkAbout1668A WORKERS'COMPENSATIONDECIARATION APPLICATION F4R PLUMBING PERMIT `f'�'��
I hereliy afflrm that t have a certificate�of consent io self 7eA667A U
. insure,o�a certifico�e of Workers'Compensalion Insuronce, CE Bv(REV.IOi81)
or a certifled copy thereof(Sg,�.,3500,Lab.C.) n -t COUNTY OF LOS ANGElES BUIIpiN�AND SAFET� � t
a�Y NoG7�3949�om�a,� �'sF'G"f� -F-l7r�C� I
Certified copy is heieby fur �hed.
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUI� ING r/�
Certified copy is filed wit e u �y �n c P.DDRE55 !///{,
fiondepartmenf. MBER fIXTUREORITEM � fEE �OCAUTV
� Date�.��Appicant f 1�'� 7j• WATERCLOSET NEAREST �
r� BA7H TUB CROSS ST. /
CERTIFICATE OF EXEMPTION FROM WORKERS' /
COMPENSA710N INSIIRANCE OwNER
(This�acfion ne�d nof ba complefad�f the work inrolv�d by SHOWER
1ha permN i�for onr huednd dollun(3100j or Isss.) �7 �AVATORy � MAIL
�� nooaess
I certify tha�in the performance of the work tor which this
permit is issoed,I sholl no1 employ ony person in any manner f SINK CITY �1� .TEL.
so as�o become subject lo the Workers'Compensation Laws. DISHWASHER �
I CONTRAQOR
� � Dpte Applicont CLO7HESYJASHER ApORESS
""""'ICE TO APPLICANT; If, ofisr making this Certificate of SWiMMING POOL RECEPrOR
� mplion, you should become subjed to Ihe Workers' j� +�/��'`/
�.ompensa��on pro�isions of fhe La6or Code,you must forth- �qN/N SPRINKLER SYS7EM ��TY �'O" T� "�
� with comply with such provisions or ihis permit shall be STATe �i uC !1
deemad revoked. � , WATER HEATER � LICENSE NO. V CLA55 �:�
LICENSED CONTRACTORS OECLARATION DiSTRiCi N PkOCE55E�Bv
I hereby affirm that I am licensed under provisions of Chapter 9 GAS Sv57EM Ol1iLET5 � �\���
(commencing with Section 7000)of Division 3 of ihe B�siness OUTlET504ER
and Profassions Code,and my license is in full force ond effect. 5 PER SVSTEM FINAL � J �r,� VALIDATiON a
License N mber����� Lic.Class�_ OA� � �
�i f� . FINAL � „,!� (,).
Contrac}or t� l Date 9�-� BY �'";.'r"�_�'`"^' �
I � I om exampt under Sec. �
8.8P.C.for this reason . . "f�� �'��A W
Plan check fee ��. e� d m 5 �'
Dore: p�UM81NG PERMIT ISSUING FEE S � �
� Signcfure I a ;- %(i J�n �'
TOTAL FEE
� ., ��ESo�
- SINGLE FAMILY Plan check ppplicont L r � j`E 7 �
HOME OWNER-BWLDER DECIARATION Nome
.�'eby oKirm thol I am exempf from the Controctor's license Address
..,for fhe following reosan($ection 7031.5,Business and
. �Professions Code): City Tel.No.
❑ I,os owner of ihe property,will da the work ond ihe
shucture is not intendad or offered fo�soie(Sec7bn � �
7044,Business ond Professions Code). � .
LONSTRUCTION LENDING AGENCY '
I hereby affirm thal there is a construction lending ogency for �
the performonce of fhe work for which ihis permi�is issued �
(Sec 309Y,Civ.C.).
6�nCld F N�rRa—
lender='s RdCtreto
I certify thot I have reod Ihis applimtion and stafe Ihat the �
above informo�ion is correct.I agree�o comply wi�h oli County -
' ances and Stote lows regulating Plumbing,and hereby
ut riz repre�'en a✓ es of this County to en�er upon �he
. ve- entio r pen for,�ns� t� p ses
n����! SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permiitee oare CJ
.. i��. . . . .. .. . . . . . . . .
� F. � � f �.. • .
�: �� �. �r w ��
�tiaae�� � �� onT� ird5PEC70R'SSiGNaTuae MSPECTOR'S NQTES . O'�PiIvER-BUiLDER DFCI.4RATION �
u' Ncee=_iF,a w I i . •
� � J -� �.i 4 � I hereby afflrm ihor I am exemp�from fne C .t c � �';
�ROUCH �U'.' 1 s��l�l. . �`� ' � � Li.-ense L�w for Ihe follow rg reason (S�d on OJ15,
�A��,.F h�- -:'"--_ ���t . . . Busincss ond Professionz Codej�Any city or ty f�-h
� requires a permi�to tonstruct after rmprove,demolish.
G�5 VEF+7 I�, � or repair any s}ructure, prior fo Its issuonce, also re-
HOi�^�e�Tf3 s 7-a � � . � qulres the applicon�fo�such permit fo lile v signod ifote�
.—. _ _�
PLU� ir ;,-i? =�' • ' � . .� menl thcf he Is litensed pursuon'/o ilee provrs ons o�tbe
—"' "`��- � �'---"" --"—���—"� ' �l�"--- Coniroctor's L cense La�w(Chopter 9(commennng h
GAS TE 7 I ���
LJ?IUTV CO.n:nT���'!;=J � � Settion 7000)of D/vision 3 of the Buslness and Profes-
- __— � sions Code)or ihat he is exempf therefrom and fhe bos'rs
� � � - � ♦or ihe ofleged exemptlon. Any viola/ion oi Sacfion
r----..r�-�---.___..�—f.`-^�.- c7 .—' . .
+F'�Nnl (�'�r,frr u�n _tr.,nf ' � 7031.5 6y any appllcant for o permit subiects fhe appli-
conl to a crvJ penalry of not more fhon frve hundred
doUars($500):
ItiLlJ57 J: ' ' ❑I,os owner cf the properly wlll do th�wark and
w.a5 -F-=.-:,i �' � � � ihe structure is not�mtended or offered for sale. �-'�
i —"` ""`_""" � . ($ec.7044,Business ond Pro(esslons Code: The C< ,
, . ` � � � � , . ' ' tor's Gleense Low does not apply+o an owner of property
- ,� � . who builds or improves fhereon, and who does such
- � � � � - work h7mseff prorlded}hat such improvements are nof
. � Intended or o�fered/or sale.If,howevar,the building or
. � � . improvement is sold wifM1in one yaar of comple�ion,�he
owner-buifdar will have}he burden o/proving Nnvt be dld
� , pot build or Improve for iha purpase of sale.)
I am e*emp`under Sec. .
� B&P.C.for this reason
-- — Date
�WllEf _ I
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