HomeMy WebLinkAbout1071A (5) �— -— -•---_. _- _ . _ , -- -------------------_. :-.____�..._
WORKERs�oM�NSAT�oNOE«ARAT�oN , APPLICA710N fOR PLUMBING PERMIT ///777
. I hereby.affvm that I hpve a tertifimte oF tonsent lo Self 20�0026OPW 6/87 . y � C,�
in�•e,or a cerlificate of Workers'Compensation Insuronce,� ,76A667A � � � E , ��
or��,�,t,ified o y�here Se. 800,lob.C.) COUNTY OF LOS ANGELES DEPT"OF,PU�LIFC,WORKS U
Q�r`'.Y`rY'$�O�`'Y -�Y�-7��?!Nd � - ° '�� � � f � � �'
' Cenified copy is hereby furnished. ' n �
�, ' ' ' FOR APPII�P.NT t0 fllL IN(7RINT OR TYPE) I�. BUIIDING
;'y��� Cenified copy is filed wi�h Ihe counly boilding Inspec- � � ' , ' ADDRESS f� /v�
f tio d parlmeM. . , ' INUMBE2 i FI%TUREORITEM � FEE'� �� � * F .I.� � .
,��,�G IOCALITY
� Date"�T!/b�AppliGanl WATER ClOSET I `� �REST ': �
CERTIFICA7E OF EXEMPTION FROM WORKERS' � BATH 7UB � , � CROSS ST E � 1 IV ' �
� COMPENSATION INSURANCE � � ° ''}' �� �-° � ' F r . �
(Tbfs s�ttion n��d no1 b�[omp�d�d{f th�work Involrad by SFiOwER � �E° ' � 1�
� fh� .rmit k fer on•hundr•d dollan f100 or I�ss. � . . �MAII p r.
P I � ) IAVATORY ���ADDRf55� IvE
1 terfify Ihbl in the parformonte of the work for which Ihi, � �-�� C� � + i +1 Q
� permit fs issued,I shall not employ any person In ony manner SINK � � �§CiTY� � ' f �:�. N l)
sa as fo become subjad to the Workers Compensafon laws,' DISHWASHER 3 COMeAC10R� ����
Do7e epplicant CLOTHES WASHER x AD�RFSS� "� �� �� � �
NOTICE 70 APPLICAM: If, after moking thls Cerlificale of SwiMMMG POOI RECEPTOR
• Eaemp�ion, yoo ahoold become subjecr ro the Workers' ' � ��Ty I s � � �
Compenw�ion provtsions of Ihe Lobor Code,yoo musl forih- LqwN�SPRMKtER SYSTEM ' E ^ " �f����
'� winc �omply wHh wch provisions or thta permit ahall be � � 5in1E ,�i � ' � � � I b UC. r�
� tleemed re�oked. ' '' ' WATER HEAiER .. UCENSE NO. • � I �'�'i CIA55 "�4
�' LICENSED CONTRACTORS DECLARATION ' - I oiSte.r NO.i� h e ;. p PR Eo BY
� I heroby affifm thot I am licensed under provisions of Chopler 9 GAS SYStEM OUTIETs �� 1 F ; i F•i ! i { � �
I (commeocing with Section 7000)of Dividon 3 of the Business OUTlET50VER .� �.{ {� K �
F and Professions Code,ond my licensa ts In fuii forcd�and eHetl. , 5 cez svsrenn KINAI. 4 �� ' � f �� VALIDATION 0.
i C Z�. �� � � R : DATE�� �� �� ��; ,� � Q
�iro e umber�l�� Lic.Class t V
��-�OSr..��Co Dote 2-28-9`p ,� �; BY'°`Y i�1' °� t I E � '�
' con+roc
�'� ❑ 1 am exempt under Sac. � . � i ' ��, p � p, i:� � I� . V.
y 8.8P.C.for Ihis recson � ��� f ;� F 4�
i
� '� Plan check fee a� Y k � � cn
1
Date: pLUMBING PERMIT ISSUING FEE S ��; ��, � ���' �y k �' � z'
stg�cw�e �� � k ;
1 d ' TOTALFEE � j ' �'� � I' � I .
� � ' � " Pfan check appficanr � �� �� f � � � � �� �7.� A
SINGLE FAMtIY .'',j
I HOME OWNER•BUILDER DECLARATION .- Name I � + F � �� � �s • • � •5 I
1 hereby afiirm that I am ezempt from tha Controttor s Licanse '. F � � �!i
,�,/� low for the following reoson{Section 7031.5,Busineu ond �: Address � � �G. ��I '������I ° • � U J��
y Profesaions Code): � '. Gi�y Tel.No. � ' S # 'S f � ' . � ( .. . • o
I ❑ 1,us owner of the properry,will do the work and tha ' I 7 t r� � 4 p���i r f `�' °� �z 5�� i�
� shucture Is no�in�ended or offered fo�aole(Section�� � p p � �
f 70M,6uainess and Protesslons Code). , . � ' � , � 5 rcd &��� � a 5 2�4-8 8 !�
} CONSTRUCTION LENDING AGENCY� � ' ' + �� ` � �� � � � � � I�
I hereby affirm thot there is a conshudion lending ogancy io i� '� � � � �i� �� � ' . �� !�
�. Ihe performonce of the work far whith this permit�s iss ed�' � � � g �� � y{ �
I ISec.3097.Civ.C.). - . �� � � P . E���� 1� � ' �.
� i t r s �, � �
�' Lendar's Name r r } 4 � ` f �
, � I ." � E ; +e k . } � i .
d
' LenderiAddresz ' .� .. . f' ,�: s��� : �j f p t ,�.I . . ,
I carhfy thot I have read this applicotion ond siate thoi the; � � �� {'� � I i
t _ o6ove'niormotion is correcL I ogree to camply with ail CouMy�. � ° a � I �� � �
� ordinances and Siate laws regulaling Plumbing,aad hereby�, S � �G ���j �E'� ��,I I � .� '.
� �au�horize r re3enfahves af this CouMy to enter upan Yhe j � . l f� ,. .
above- ned�pr r inspection purposas' ��� i i � ` s � � �� � � � � � �
�� �� �r SEE REVERSE FOR EXPLANATORY LANGUAGE I� ° ` �, � � �; ��
1� F r t . ��j.
. � I
� Siqnoture ,,Date . � i : . - �� , . -
, ��r'< '� f i
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n?FeOvn�S DAtc WSPEQOR'SSIGNqTUnc -INSPECTDR'S PIOTES �:1;+iNEP„3U!LU�F.�,�ECI,ARAiIQ�!,��... .
�`JDE2<LA014'ORK .. , I hereSv nf(itm thnf I�om c. mpt fro�n tne Cnn•rc:_�or'•.
.. .. _ ., _ _ ,
.c
RCUGH:PtLh13IVG � ' '�� , lic=nsr. Lav: for Ihe fo4o�m1^g rca;on (.'+cr.�ion 7031 5. �
GA�P;FiNG � ' ' ' -� - � - � ' - � Eus7ness end Pro(esslons Code):Any ctfy or caunfy w.S�cS ,
GAS VENT . � . . � - . �equi�es a pe�mlt fo crosfruc�,aher,improve,d�moGst �
H�?W.;TE�H[ATfR . . , ' er repo7r any strucfure, �rlor fo its-tssuoncr„•clso re�
qulres 1hn e.pplicont lor such pennit to file v s���cd.<.lale�
�PtC':d:nlG FlxT�•RES - - ' �� " - ment f�uf h^is ficonsea pe+rsuoN lo tl:e prcvision;of 4hc -
GAS TESI � � � Cenlrador's Ucense Low/Chapr�r 4(mmmencl:,y•��i�h
�, - ...,, . ,':�._ ,. .. ,,.
UTiIITV CO.NOi�FI�D , - �. Secl�on 7000J ol DiWsicn 3 0l fhe Buslness and Pw�cs-
_ , _ . , � srons Ced�)or lhat he Is excmpt Iherrfrom cr.d rhe bosrs
- r ` c7 - � - � � " lor ihc allcgcd exrv+pRcn. Any violalla��.oi Srdion
`�'^:n �. �C,�rtlr. n .Jro�.��. • . . . ... 709I.5 by cny app(iconf for o p^rrnil sub;sds Ih^ar pli. .
, - 'tcnt ro c civil penc(ly oi nol morn Lhan five hundred �
. _ -_ � ' - � - -� dollors(SSCO).:
�N^VST21�L� ❑I,a:aw�n_r c`�he preperfy�,�il;do Y:-e we�c.ana .
vd..STE n:FZOVa: � � � . . the s'ructure 1:ne!ir!ended cr offerad for sole.
- � . . � (Scc.704a,Euslness ondP�o/e:sions Cadc: iheConfrac� '
., ,
. . : . . . , .':_ . . .
� � � . - � � � � � , , . . „ tori Llcer,s�e lowdocs not apply rn cn o��mer cf prop^ny '
� _. - � � � -� - � � � who 6uilds or lmproves Ihcreon, e�d w�F.o doas evch
� � ' ' "� .. � �'� _ work hlmself provided Ihef such impravemenis arr nof
_ � � intendcd or oHered!or safe.1/,howcve�,the bvilding or
� � ' . � � � ' ��- -- imprcvemen!is sold'rvlthtn one year of conpletion, IF.e
. ' � ownorvbv�ldr.r wil(have�ho burdan o�pro�tng thc�he d�d
�. . � , _�, nof buiid or tmprove for}hc purpose o�svlc.;
� , . . � ��.�:_" ,� . '� ir._ .
t am exemp!under 5�::. ,
. � _ . ,.. :'-. . _
� - - � - 8&P.C. for rhis reason_ . _
� � - Date--_. --
. � Owner_ �.
� � _ . . . . .. . . �
INSPECT02'S NOTES
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