HomeMy WebLinkAbout1601A , _._._ __ . _ _.. _ . , _ . . .. _
� '_WORKERS'COMPENSAYIONDF.CLARATION vuave •
;. ;eby er£,=m ��a< < he,,e a cerNficate o��a�a�,�to self �a.,��=..a, APPLICATION FOR PLUMBING PERMIT�
I e,or e certificate of Wmkers'Compens�tion Inaurence,or . � .
. ;ifed copy thereof(Sec.�800,Lab.C.)
'�S S1'Al'i FA� COUNTY OF LOS ANGELES BUILDING ANDSAFETY ��'
5. Y No. Campany
� Cer[ified copy is hereby Nrnished. FOR AVPLICANT TO FILL IN(PRINT OR TVPE) BUILOIN6 /./i�I/ Y
p� � ADDRESS }`� — 1
�e. CertiFed copy ic filed with the ounty 6 11di nsDection NU�uIDER FIX7UPE OR ITEM � FEE
��Q Aep°��tro�e��td� v WATER CLOSET LOCALITV
�4e� �/—"yy�S�—Applican NEAREST
19 ��� / BATH TUB � CROSS 5T. S/�'f
�te ZERT(PICATE OF EXEMPTIO ROM WORKERS'
vt � COA4FENSATION INSURANCE SHOWEA OWNER —
�}' LAVATORY . MAIL �„
�� �,section need not be comp teted if the work invoHed O noortESs a
I �e pexmit is tm one hun4red dollue (SS00)oe lesaJ SINK �
}rt , CITY TEL NO. O
�� �ify thal in the perFormance oC ihe work for which this DISHWA3HER CONTRAC70R �
Jd t is iuued,I shall not employ any pwson in any menneo p
F 'to become subjnCt to t W kere' ' n alion Law. CLOTHES WASMER �
� . ADDRESS V
� �A�P11Ce^t SWIMMING POOL RECEPTOP f a
�J �E TO AYPLlCANT' t,after king this lirtiFcate of d7V TEI.NO � �- y
`PS t�o� LAWN SPRINKLEA SYSTEM
STATE T LIC. �
p you should Decume ubject to the Workers' UCENSE NO�D CIASS C.�t
its epsation provisions of the Labor Code,you must forth- yyqTER HEATER
he p�mply with such provisions or tMs permit shatl be DISTRI T NO. P OCESSED Y
vj �drevoked. GA93Y9TEM OUTLETS
Q11 i LICENSED CON7RACTORS DECLARATfON o� �
[i� OUTLETS OVER
( iy affirm that I am licensed under provisions of Chepter 6 PER SYSTEM
I �mencing with Section 7000)ot Division 3 ot the B��si- � F�Np'���"� VALIDATION
I �d Professions Code,and my license Is in full torce and OATE
'Number��i,ec� Lic.Class_(r 3� BV AL r�y.{ryyy_,
:torF� . PLb Dete
�' em exempt irom the�licensing requtreme�[s a6 I am a Plan check fee
:ensed architect or a ragistercd professioaal enyneer pLUMBING PERMIT ISSUING FEE S � �
� ting in my protessbnal capacity (Section 1051,Bus• ,
tss and Yroteasions Code). . TOTAL FEE Q
— i
I Reg.No. Dete Plen check applicant
:1b0'IF
i : HOME ON'NER•BUILDER DECLARATION Name .
! nda.... r� ` • 'k 5
��y affirm that 1 am exempt from the Contractor's � �
',Law for the foliawing reacon(Sectbn.7031.5,Busi- City Td.No. ,�'P •�L�F�Q
I }Protesaiona Code): .
�
ps owner of the property,am axclusiveiy contracting , `�� ��'"
!h licensed co�tretto�s to construct the prnject
i fction 7044,Business and profeasions Code). ��;G� �Q� �
�' � CONSTRUCTION LtiNDING AGENCY ���
j y affirm that there is a construclion IendinQ apenay - � �
I 4performance oT the wotk for which this permit is . �
pec.3D97,Civ.C.).
k 5I Name
� l Address
�� ff that 1 have read this appiicalion a�d state that the
�� Iformetion is corcect.I a�roe to comply with a�l Cou�ty SEE REVERSF.FOR F.XPi.ANATORY LANGUAGE
I �:es and State laws regulating Plumbing, and hereby
� �e representalives of this Cou�ty to enler upon the
� jFntioned/p�r pe for inspection purpases. �
E- ;�'.!� ��.�,� �/�j
, . �lar f ermittee D , . ..
I
APPROVALS DATE INSPGCTOfiSSIGNATURE INSPECTOR'S NOTES ' � � �, OjYNLR-BUILDER DECLARATION
� UN�Efl SLA��"JOFlK ' " - ' . . � � � '�
Rovcr�F�u,ti�t�wG - - � � � � . 1 hrreUy affirm thae 1 am e�empt from the Contracto�
" � - Liccn3c La«�(or t(ic tollon�ing rcason jSection 7031..
, cFspiwric: � �•�- � - - � � � '� "' � - � � � � �- Businers artd Profesriorts CadeJ: Any.ciq�.ar coun,
GAg vENr '�, . —^ - . .. . �,� � . .. � . . . ._ . _. . ... .. . . .. � . . w4�id� requircr a pernrit ro cou.[tntCt. altcr. intpra�'
r{orV.sar�a t�[nr�-� . _�'� � deuiofish,nr repair.dny strucfure,prior to irs rrsuartc
��ur��r,iNsF�r.ruv�s -- -- � - �� � - � � . , . . � � olro rcquirea the applrrenr for.cuclr.permir to jifc
�. sig�red�.smturlen:�lhet 8e 'u lirensed pt¢sumu�ro 11
cns Yrsr � - � � - •. . - � � .. . �proricrars uf 7lre Conlroctor's license J.aw/Chapter
UTILITV CO.NOTIFIF.p ��COIIVIIP!![!17$witir Sectrun�7000) of Diri.rion 9 oj tl
— . ... . ., - . .. , .. . � -, . . � Busirrers and Professiwu CadcJ o� tJra! he is exem,
T . therc(�nm mrd Ike besir for rlrc alleged exemption.Ar
FINn� .. L'n�.�i ors-�2air� � � � - � ; -- � ,�� -� - � �� ' , � ri�fatiar of Scctioi+7031.5 fi)'mr}�applicmUjo�a pern
� , � _ � � su6jects Ute opp7itmtt to a cii'il pei:atty uf rroi more tin
. .... ____ . ..._. '.'::_.,.�..-��.;�_. '
woU^r�7u.L - ' � � - . � � IirehundreddollQrs(5500/.:. . .�
�.vnS7c a���;ovA� � - � �^ � - � � -- O i,ae oH�ncr of thc pioperly aill do!hc wock,ai
,� � ... . - �-tlic structure is not�intendeJ or offcred for sale.
._ . .. _ . .. _. .,_ ....._. . ;.(Sec..i0-{35 13iesiners m�d.Profersrons Code: -The Co
. _ .' - � . � . " �� . rrccrork lim�uc Ldw docs nor appfy to mr o�rrrer
- - -- - � - - - � � � �� � � - property.irlio buitds or irnproves lherea:,end xdro dc
' �� . . . .,' , � � .. . - .. .. � serei+ x�ork lrimself proriJed d:at suclr.irnp�o��e�nci
• � - � - � � � ��- '' � �� � �� � � � � � are nor intenJed or ofjered jor safe. !j. Hoxe�rr, t
. � , � � - . �- � ' , , „ � buildrng ar inrproceineirt ir sotd widurr one ��ear
. � � � � - completimi, the owner-builder wi!! Lave tAe bwd
- � � � �--��� ; ��� -� - � - -� � � , � � . - ��� of proring tlrr.t !re did nor build or irnprm�^for f
� purpose of m1c.J ; �,�_ . ..
. _ I am exemp[undcr Sec.
I3:S;P.C.for this reason '
n:,tE
_ o���,��
IfJSPECTOR'S NOTES � � � � . .