HomeMy WebLinkAbout1703A �� WORKERS'COMPEN9ATIDNDECLARATION o�ws�vw �
1 hereby aftirm �ha< < h.�e a certificate o��o��<<0 9e�f �a.���=..e, APPLICATION FOR PLUMBING PERMIT
. insure,or e certircate of Workers'Compenantlon Insuronce,or '
�a ce ifiad Copy Ihereof(Set.3800,Lab.CJ
D�X/�� P �j-�p.�t �� COUNTY OF LOS ANGELES BUILDING AND SAFETY
icy o. Com any
� � Certified Copy is hereby furnished. FOR AVPI.ICANT TO FILL IN(VRINT OR TVPE) BUILDING
ADORESS �
� � Certiffed copy is flbd with th count il i�apecti n NINNBER FIXTUqE OR iTEM � F� LOCALITY
de e men - L WATER CL03ET
Date_y��Applicant NEA EST
BATH TUB CRO55 ST.
CERTIFICATE OF EXEMPTION FROM WORKBRS' �
COMPENSATiONINSURANCE SNOWER OWNER
LAV ATORV MAIL
. (TNis section nad not be completed if the wOYk invOlved � ADDRE65
� by the permit i� Pm o�re huadred do�ars(5100)m leaa.) S��yK }
� CITV TEL.NO. a
O
I certlty that In the performence of the work far which this � DISNWASHER V
� permit is issuad,1 shail nbt employ any per n i ny manner CONTRACTOR G �
� so as to yeco e subjett tn th�7 kera' don La . ' CIOTHE9 WASHER AODRESS I� �
' Dat Applicant-y�����/ SWIMMING POOL RECEPTOR V
I NO CE7����UCANT:1.aftf er m ing thfs Cettificate oT GTY TEL.NO. / f a
�, Exemption, you should become subject to the Workers' LAWN SPRINKLEH 3V6TEM � �7 N
Comprnaation provisions of the Labor Code,you musi forth- LT ENSE NO.Ja CLASS z
' with comply with such provisions or thia permit shell be WATER HEATER .
deemed revoked. GAS SVSTEM OUTLETS DISTRICT NO. iROCESSEO BV
�� LICENSED CONTRACTORS DECLARATION OUTLETS OVER � I7")�
�.� I hereby afthm that I am licensed under provisions of Chepter B PER SVSTEM ,
9 (commencing wi[h Snction 7000)of Division 3 of the Busi- FINAL VALIpATION '
� ness and Professiona Co�e,and my license is in full force and � �ATE `� �
eftect.
FINAL
�� License Number�� Lfa Ciess G�e_ gy
r Contrector�f�/�� Date
� I am exempt fram the licansing requiremm�s as I am a Plan check fee ' .
licensed architect or a registered professional engineer pLUMBING PERMIT ISSUING FEE 3
acNng in my profesaional caDaNty(Section 7051,Hus- �� 7 p�F .
' iness and Profesaiona Code). TO7AL FEE �
,. �� • ��Q N L�
. Lic.or Reg.No. Dete plen cb�Ck�ppqunt •I Ie.3 r 5 0
. HOME OWNtiR•BUILDER DECLARATION Nem� � `
;�SC.�
I here6y a�rm thet I am exempt from the Contrector's Atld�ns �
� License Law for Ihe followin ruson Sec[ion 7031.5,8usi- �4 2 V��1
8 ( City Tai.No.
� ness and Rofessions Code):
� I,as owner of the DropeHy,am exclueively contracting . �
� with licensed,wntra[tors to construct [he praject ,
(Section 7044,Businesa and Profasions Code).
CONSTRUCTION LENDING AGGNCY .
� 1 hereby affirm thet there is n constmction lendinQ aeency �
for the pertormance of the work for which this pumit is �
1�
issued(Sec.3097,Civ.C.). � �������(.`
�Lendels Name �
� LendePs Addreu ,({ e/ ���
� I certity that I heve read this application and state[hat Ihe �'JJ �
� above Informalion is correct.I agree to comply with all County SE£REYERSE FOR EXPLANATOPY LANGVAGE �� �
ordinances and Stete laws regulatinQ PlumbinQ, and hereby . . �
i uuthorize representat�eb ot fhis Counfy �o enter upon the
�, above•y�Rttoned pr ert ioapection ur0oses. -
R/ �
� gna e ermittee Dete
f
-. �.`>
t,arFlOVr,Ls� Non7[ Ivsr[ciOrjssiG�va7uRtZ INSPECTOR'S NOTES ' OtiV'i�FF.-BUlLDER ATCLARATION
uvoer���an evo�K - c( .�,,.,r.� � � ' .
— -G��2..,�� � -�y%}��t' ,.,.. .. .. . � . � t here6y affum that.l am erempt frtim.tlieCu4tractnr's
zoUcti Pw^neiNc � �-I.icensc�Law tor�thc�followin�rcason(Sectioir 7091.5.
Gn5 PIFING..: . � . . ... . .. .. . . . . . . . . ., ..... . ._.
13usiness and Prafessions CodeJ: �tny cir}� or comuy
Gns vE NT•.'t __�l. . _ . . . . - . . �. . � . - ._- . � . . - x�hicli mquires a pernut lo conrtNcf. e!ler. improre,
'�. HOTY�AIEFi H�ATER � ' � � f1C1ltOIisJ7,OY lCpaiY�rly riructur:,prior to itt ISSItQiICC,
��u^aa,�Nc FixTURes . ..- _ . .... _-' . .. , �. ' � . ' �� als� �equires�.�the applicar.t for sucli permir ro fite'a
_ .'-�-�signe2�iratemem`t&ct�lte�is licensed�pitrsuartl.to thc
cns 7e57 � - - � �� . p�ovisimts nf the.Contrnetor's Lieertte leK•(Cf;apler 9
u7iurveo.NOTiFieo - , � � .� Yrwnmericing wiNr Section�7000J oJ�Dirision 3 of the
—--��— � -- - � �� � � Uusinesr mtd lYojessiarrs Code) or ther Ite is exentp!
� thcrefronr and the basis for�7�e ailegrd exemprion.Any
. FiNc,�-. - . L'r.�r_4-a�i �^en� . � � � '.. ' . . . . .. �' . - - ' riola�inrt of Sectiar 703(.5 bJ'anl'pPPlicmftlora pennit
� —� - . . - . � ' � ` � - ,�ibjecu rLe applitant to�a ti��iJ Pencl7y oJnot rrtore than
INDUSTRiA� —� -- .". .. ' .. .firehurtdredda7(prr($S00/.: �
P;aS7E a,aPFovRI' �� -.- . .. .. O t,as o�vncr ot il�c PtoPt�tY��i➢do Ihe�cock.and
, � - . . � � ' � � � - ' � the stnicture is not intendcd or offered tor salc. �
...�� _ . . , _. �
� .. ._. . . .. . . _ � � , � (Se�.70�d,'rusiness•a�+d f'rojessions Cod�'.��Tlie Cor�-
'�, , � � , . � .. . � � � . �..- � iracror's Liccnsc Ln�v does nnr app7�� fo m� ow�ncr oJ
. , - ' . 1 ` .. . .. - . . � . propert)'.iclw bid7ds or improv'es thereuit.arsd mAo does
. ' �, :��,. . ', , , . -.- . . .- . . -� .sucA.wor8 Gimself pmrided thar sucfr improverrvents
, , � � , � � � -•-� �� � � -. _ - ' - cre��not intendeJ or ojfered jor scle. !j, howerer, die
� -' -� � � � , � , building or irrprorenten� ic tofd x�itLin oi�c ycar of
. �, �r - completiore. Ihe aw�rer�builder wif! karc N�e burde�i
� � . .. .��� ,. . . •.�'���\.. ..- .- . . . . . . . �. of praring tf�a� lie did nor 6uild or improne for tlre .
��� . � � .. . . .. . . � � . . � . .. p�rposc ojsalc.J .. . .
' _._ `_ - , I am ezempt undcr Sec. > ,
� _
._ B�C'P.C.for this.reason ,
�+.' , ,� -
f ' —_�. Datc
, . . , . ., . .. Oh�ner
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•� � " ;IfJSPECTOR'S NOTES � � . � .. � .
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