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Home My WebLink About1466A (8)w k r comp y wr suc provmons. or Is, perms s a e . deemed revoked. - 1 WATER HEATER - ` STATE " LICENSE NO. WORKERS" COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT - I hereby offirtn' that I hove a certificate of consent to self j6A667q - - i insure, or a certificate of Workers' Compensation Insurance;- CE 817 (REV. 10/81) -- ,' or a certified copy thereof (Sec: 3800, Lob C.) . I COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. .. 5 PER SYSTEM ,Company Certified copy is hereby furnished VALIDATION ' �v� Class FOR APPLICANT.TO FILL IN (PRINT OR TYPE} BUILDING t Certified copy is filed with" the county building +nspec- E]' License Numb,e Llc flu' ��r, �j Contract—WI L d,tl " n�'Dote • ADDREss FINAL BY; tion department. .i :' :" NUMBER FIXTURE OR ITEM FEE l lAppliA,/' -� WATER CLOSET . LOCALITY Date ,ant - NEAREST - CERTIFICATE OF EXEMPTION FROM WORKERS' - BATH TUB CROSS SL COMPENSATION INSURANCE' - - OWNER .. PLUMBING PERMIT ISSUING FEE $ {Thin section need not be complNhe •d if twork Involved by SHOWER I' Signature itis permit Is for one hundred dollars ($100) or fest.) LAVATORY MAIL ADDRESS - TOTAL FEE - a - I certify that in the performance of the work -for which this .. - Plan check applicant - - permit is issued, 1 shall not employ any person in any manner SINK CITY��TEL NO.' ... Name -- - -. so as to become subject to the Workers' Compensation Laws. - I,; I hereby affirm that I am exampt from the Contractor's License Address + - + .I DISHWASHER - - - - CONTRACTOR i� _' .. Date" - `Apphconr - 'after �rhis CLOTHES WASHER ADDRESS % - City ,Tel. No. _ NOTICE TO APPLICANT: if, making Certificate of Exemption; you; should ecome -subject fa the Workers' SWIMMING POOL RECEPTOR' A CITY TEL' NO.ZO j - Compensation provisions of the labor Code, you must forth- 'rh 'I 'rh h th' h II b LAWN SPRINKLER SYSTEM - .. �;�! ` - - - M1_ - w k r comp y wr suc provmons. or Is, perms s a e . deemed revoked. - 1 WATER HEATER - ` STATE " LICENSE NO. LIC. CLASS -' LICENSED CONTRACTORS DECLARATION - DISTRICT NO. BY I hereby affirm that I am licensed under provisions of Chapter 9 - GAS SYSTEM OUTLETS - p ,' (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER, ri�OCESSED and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION ' �v� Class DATE License Numb,e Llc flu' ��r, �j Contract—WI L d,tl " n�'Dote • FINAL BY; ; IX O V a1 am exempt under Sec. l a+ 7 B.&P.C. for )his reason T' Plan check fee t --Dot.-'®� PLUMBING PERMIT ISSUING FEE $ I' Signature _ - TOTAL FEE - a - - Ipr1 - Plan check applicant - - - �' SINGLE FAMILY HOME OWNER BUILDER DECLARATION Name -- - ' - 6A - I,; I hereby affirm that I am exampt from the Contractor's License Address + _lj # Sr, Law for the following reason (Section 7031.5,- Business and- _' •• • ! Professions Code): '. - ' +'' ) - - City ,Tel. No. - (� • 1 650 ❑ I, as owner of the property,' will do the work and the structure is snot Intended or offered for sale (Section -' • • • 1 El 5.� v - 7044, Business and Professions Code). - - - M1_ - - - - - - ' { 0210-84 t i CONSTRUCTION LENDING AGENCY,- '. I hereby affirm that there is a construction lending agency for (-- + the performance of the work for which this permit is issued + (Sec. 3097, Civ. C.).: L Lender's Name- ame Lender's Lender's Address Ili I certify that I have read this application and state that the ( above information is correct I agree to comply with all County- '! ordinances and State laws regulating Plumbing, and hereby- i,-authoriz representatives of this County to enter upon the '- -' -_ -.'ri. --: --- P''-•- -" - - -+ V, bo - entione petty fo �ispectlon p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ��. Signature of P rmittee - - i Date 7`-" - APPROVALS DATE. INSPECtOR'S SIGNATURE UNDER SLAB WORK ROUGH PLUMBING' n GAS PIPING j GAS VENT HOT WATER HEATER - PLUMBING FIXTURES GAS TEST UTILITY CO. NOTIFIED - FINAL CCJf Ln(er re .Yrors(� INDUSTRIAL WASTE APPROVAL - - INSPECTOR'S NOTES ' OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): Any city or county which requires a permit to construct, alter, Improve, demolish, ar repair any structure. prior to Its Issuance, also re- quires the apphcomf for such permif to fife a signed state- ment that he is licensed pursuant to the provisions of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prof— signs Code) or that he Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the apple- - cont to a civil penalty of not more than five hundred I dollars (5500).: ❑ I, as owner of the property will do the work, and the structure Is not intended or offered for sale. (Sec. 7044, Business and Professions Code: The Contrac- for's License Law does not apply to an owner of property who builds or improves thereon, and who does such j work himself provided that such improvements are not Intended or offered for safe. If, however. the building or Improvement Is said within one year of completion, the ] owner -builder will have the burden of proving that he did \ not build or improve for the purpose of safe.) t i1 I am exempt under SPC. B 8 P.C. for this reason r . Date Owner N r a, INSPECTOR'S NOTES G �i ;. I{