HomeMy WebLinkAbout1347A � °�gF`a'A�f°�°�`L"R��`°h '°"°a'" APPLICATION FOR PLUhABING PERh�11T �
I hereby affirm that I have a'certificate of consent to self c¢en(z-eoj
insure,or e certificate of Workers'Compensation]nsurance,or
a caftitied copy Iheraqf(S�e.3600,Lab.C•)
� COUNTV OF LOS ANGELES BUILDING ANDSAFETY
...Policy No.� � '�1 CompanY�laYI{� _
I � Certified copy is hereby furnished. FOR APPUCANT TO FILL IN(PR�N7 OR TYPE) BUILDINCi f
� Certified copy Is filed with the county 6ui]ding iospection
NUMBER FIXTURE OR ITEM • FEE ADDRFSS
, Ae� tme LOCALITY �
WATER CLOSET
Date '– Applican[ Q +•�� NEARESY
BATH TUB CR058 3T.
CERTIFICATE OF EXEMPTION FROM WORKF,RS'
COMPHNSATION INSURANCE SHOWER OWNER ��
(This secdon need not be completed if the woik imolved LAVATORV MAIL
by the permit is for one hundced dollars ($100)ar less.) ADDRESS��_�'�_� '- . �
SINK CITY � '� T L.NO. �
I certify that in the performance of the wmk for which Ihis DISHWASHER
permit LS issued,1 shatl not employ any person 1n any munnec CONTRACTOR Q. �`' �
sn as t�6ecome su6ject to thz Workers'Compensation Laws. CLOTHES WASHER U
Da[er 'r-Q' �ADDRE58i'�zi F
L�Applicant . — SWIMMING POOL RECEPTOR
U
NOTIC�TO APYLICANT:If,after makinR this Certificate of C�TV j TEL.NO. �-�
Exemp[ion, you should become subject to the W'orkers' LAN'NSPqINKLEflSYSTEM STATE LIC. U�
Compensation provisions of the Labor Code,you must forth- �-
with comply with such provisions or this permit shall be Wq7ER HEATER LICENSE NO. CLA35 . —
deemed revoked. DISTRICT RgOCESSED BV
GASSVSTEM OUTLETS � �� /
LICENSED CONTKACTORS DECLARATION OUTLETS OVER ���1
r22e�.:'L'–vr.�
I hereby affirm that I am licensed under provisions of Chapter 5 PER SVSTEM `
9 (commencing with Section 7000)of Division 3 of the Busi- " FINAL �/Ae/IDATION
ness and Yrofessions Code,and my license is in Fui]force and � C�P DATE
effect.
�r� /� F�NA� ���r
License Number A �'D— Lic.Class �`���.1 �
eV
Contractor��_ __ Dxte������Z
� I am exempt from the licensing requiremente as 1 nm a Qlan check fee
licensed arohitect or n registered professional engineer pLUM81NG PERMIT ISSUING FEE$
acting in my professional capaciry (Section 7051, Bus- ��/�'� �
iness and Professions Code). TOTAL FEE ,7�'
�r..7
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER nECLARqTION Neme
I hereby affirm [hat i am exempt from the Contractor's Address �
License Law for the Pollowing reeson (Section 7031.5, 8usi- City Tel.No.
ness and Protessions Code};
� I,as owner of the property,am exc]usively contrecting
with licensed contractors to construct the project t.� ��7�
(3ec[ion 7644,Business and Pro€essions Code).
CONSTRUCTION LENDING AGENCY �`.�• � �� �S
I here6y affirm that there is e consiruction lending agency �� � • � 2,5 C
for the performance of the work for which this permit is
iuu¢d Ses.3ft97,Civ.C..
Fy��iaNarte_- • � ° 1 2.50i�
�'�me�ea._ 0 1,2 7�8�
I certiPy that I have re�d this applicaiion and state that the
abuve information is correct.I agree to comply with al]County SEF,REV ERSE FOR EXPLANATORY LAIIGUAGF,
ordinances and State laws regulating PLum6ing, and here6l'
aut3rorize representatives of this County to eoter upon the
above-m�entio�n d pro erty for' ction purposes.
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