HomeMy WebLinkAbout1283A � .-_.._ `r . �__.--- --- _��,.•- _ -- - _
WORKERS'COMPENSATION DHCLARATIOY ��aauw
I heref• aifirm �ha� � h.�e e'certircate o<<a�s�,< <o��< <R.,,�a-.., APPLIGATION FOR PLUMC�ING PERMIT
' insurs,or a certificete of Workm'Compensation Insurance,or . � �
'� a certified copy thereof(Sec.3800,Lab.C.)
COUNTY OF LOS ANGEIES BUILDING AND SAPETY
'�, Policy No. Company - �
� � Certified copy is hereby[urnished. FOR AVPLICANT TO FILL IN(PRINT OR 7VPE1 BUILDINO/�2'
. � Gsrtified copy e fi�ed with the counry building inspection NUMBER FIXTURE OR ITEM � FEE ADDRESS J `
department. � . LOCALITY��J7B� .
. WATER CI.OSET
, Date Applicant NEAR 3T
BATH TUB CROSS ST. �
CERT[FICATE OF E%EMPTION FAOM WORKERS'
COMPENSA7'IONINSURANCE SHOWER OWNER �
' (This secHon nfed not be cOmpleted 1f the Work invohed LAVATORY � MAIL }
�� by (he pei111it Is �ot one hundled d011an (SIO�)or leas.) g�NK �f �400RESS V�Q'J O
. . Y D CITY '' TEL.N .(,
I cerlity thet in the perCormance of Ihe work for which this DISHWASHEF K
. permit is issund,I shall not emplo any per i y anner CON7RAC70
so as to become subject t�ken'C �j n Laws. CLOTHES WASHER O
AOORES�3� � d
�. Date ApPlic� • � W
� SWIMMING POOL RECEPTOR
NOTI E O APYWCANT:]f,after makinQ thia CertiCcate ' EL.NC��r �
Ezemption, you sh0uld become subfect to the Workers' LAWNSPRINKLERSVSTEM STATE �p. LIC. Z
' Compensslion proviaions of the Labor Code,you muat forth- LICENSE NR.r/ CLASS�
' with compiy with such provisions or this permit ahell be WATER HEATER 0
, deemed revoked. � GAS SVSTEM OUTLETS d DISTRICT NO. �ROCESS O BV
� LlCENSED CONTRACTORS DECLARATION ��
OUTLET$OVER Of
I here�y affvm that I am licensed under provisions of Chapt¢r 5 PER SYSTEM � � /�
, 9 (CommencinQ with Section 7000)of Divisian 3 0![he Buei- FINAL '
ness and Profesaions Code,and my license is in full totce end �� DATE � �� N
effect. � � � .
�`3 /_ FINAL
License Numb Li Class Y` BV .
�� � ��/
� t am exempt from the li sing requirements as 1 am a Plan check fee , �
lice�sed architect or a registered professional angineer pLUM81NG PERMIT ISSUING FEE S O
.. aCting in my pmfessional capaeity (Seclion 7051,Bus- �
iness and Professona Code). TOTAL FEE
� Lic.or Neg.No. Dete Plan check sDP���ent ,
� �` `�^ Neme
, HOME OR'NER-BUILDF,R DECLARATtON �� 2 fj`F�
I hereby aff'vm that t am ezempt from Ihe Contractor's Addren � *,� � .����v
� License Law for the following rcexon (Section 7031.5, Busi- CItY T�I.No.
ness and Profesxions Code): . � �����F�
� I,as owner of�he property,am exclusively contract�n�
with licensed contractors to construct the proJect . . '���3�C�
�. (3ection 7044,Business and Profesaions Code).
' Oh1 �-81
� CONSTRUCTION LENDING AGENCY . .
I hereby aff'vm that thero (s a conatruction knding agency � �
. For the qerformance of ihe work for which this permit is . -
issued(Sec.3097,Civ.C.). � � �
' Lander's Name,
i.. ' .�' . . .
� LendePs Addresa � �
� I certify that I have�rea�[tus appiication and state that the ,
above intormation is correN.PaY�ee to comply with ali County SEE REVERSE POR EXPLANATORY LANGUAGE
� ordinances and Statedaws��regulatinQ Ylumbiny, and hereby
� authorize representetives of this County to enler upon the
abov entioned p er t pection purp s. - �
d ���
� �g� ure of Yermittee ' .
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c,rr�r�ova�s on-re wr[cro�s.,icnnru�e �NSFECTOR'SNOTES Oti�\EP-BUILDLRDECLARA'IIOC:,-
UNDERSLAGWOFiK II��I . � .: ... � .
FlOUGH FLUMDING �f� l � �Jt��'�� �� � 1 hercuy atGrm t6at!am exempt tcom che Conteactoi s
GAS PIPING . . . . .,.. .... .. . . . .. . .. ._ . .. . .
� �-Liccnsc La«� Por the following rcason(Sectron 7031.5�
� . Businezs and Profes.cions Code): it np crr�• ar munty
�as vera'r � � � � _ . . . � . . � which requrre.r a permit to constn+et, after, improre,
��07L'JqTER H[A7GRl�+ � � � �dentolish,ar repair any srn�c�+�re,prior fo ita r.csumtce.
'LURIBWGFfXTUi-S- � � � � - � � • , . .. ' - a7s0 requires !he npplicm�t for ruch yerttlit f� file n
- . aigned sratement tlict He is (icensed punuenr ro die
� �ns`res7 '�-I - � � � . provirion.r of the Contmctor's Litense Inw/Chap�er 9
u7i�i7v co.�don�i�o r' � . � (conuttev[in� wiUr Section 7000/ of Drvisimr 3 of Nie
- �- -� � _ .. . � . . llusiness nnd PJvjcs.croirs Codc/ or Nt6r he is exempt
' fLercfronr and rfie basrs for d�e al/eged exeinpriari.rlitv
r�NA�- - L'njen �K �want, .- . . . — --- - -- . - � r. . erolaiio�rofSectimi7031.561'anl'applica��fl�raPennit
. � � � - . • , • —_ su6jects tPre applicont to e civi!pe�t6!ty oJ irot more tkan
�.rdousT��A�� .��� . � ' .. . . . IiveFrtu�dreddo!lars/5500�-;' . '
, :"�nSTE Ac'Pf,OV�,L ' ' - ' � � � � - � ❑1,as owner of U�e property��ill So Ihe work,and
� � � � ttie strucfurc is not intended or offcred(or sale.
', - � . . � . - - , ' . (Sea�.7044.'f3usinesr and ProJessions Cade: �Tfle Corv-
, . _ . . � , .___ . _ . � . � . . � - . . . � fractor's Licensc La�v does not app(y to ari ox•iter,of
-� . � � � properry.wf�o builds or impro�•es lhercon,arrd who does
� � . � ��� . . . . . . .. . . - . ' �sucA reork hDnseff p�m�ided Ihat suc1� improve�nCltfs
•� � _ � ' , � �- - � �� are nor 6ete�tded or oJJered far sale. !f.1�o�cevcr, �lie
' , ' ` � ' � . . ..... • ' � , - building or intprocemei�t is sofd �ri7hrir one �rar of
. '. � .� , ' � toir�pletiar, the owrrer-builder ���rl! lrare tlte b+uden
. . . ....- _ . .- -. . . . . . - � � oI Proving that !re did rtot bu:ld or irriprov^far tl:e
. . .. . _ .. . purpoacofscic.�, . �
� -. •.I . . . , , . , . .
_ _ ]am ezempt under Sec. ,
. . , :' B&P.C.for d�is rea5on
— D:de
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. • rI�JSPECTOR'S NOTES � , , � .
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