HomeMy WebLinkAbout1772A (10) RS'COI�fPEN9AT1'ON DL.CLARhTiON �snae��w
, I hereby atfirm that t have a certiPcate of consent to self eeen�z-eo� APPLICATION FOR PLUMBING PERM{T �
insure,or a certificate of Workers'Compensatian lnsurance,or
a certified copy thesaof(Sec.3800,Lab.C.)
�t,ltiia���'„z,s'3S ��Fy,�,L�.— , . COUNTYOFLOSAN(iELES BUlLDtNGANDSAFETY
Policy No. Company
I � Certified copy is hereby furnished. FOR APPLICANT TO FIL�IN(Pii WT OR TYPE) ADI�RESS �`�'�O //����N � E
� Certified copy is filed with the county buiLding insDection NUtdBER FIXTURE OR ITEM • FEE
Aepartment. LOCAIITV �� ��
WATER CIOSET
Date Applicant NEAREST
6ATH TUB CROSS ST. 1
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSAT[ON WSURANCE SHOWER u OWNER �, -
LAVATORY MAIL }
('this section need �wt be completed if the work invalved qooRESs Q-
by Uie permit is for one hundred dotlars ($100) or less.) SiNK d
CITY TEL.NO. U
1 cer[ify that in the perfo�mance of the work for which this DISH WASHER CONTFACTOR ��� �
permit is issued,I shafl not employ any person in any mannei
so as to become aubject to the Workers'Compensation Laws. CLOTHES WASHER ~
Date Applicant ADORESS ('fG(,f� �l��V��s���s ��(, tU
SWIMMING POOI.RECEPTOR
NOTICE TO APYLICANT:If,after making this Certificate ot CITY ��.��(✓ TEL.NO.(j 2'7 ��S"
Exemption, you should become subject to the Workers' Ir.WN SPRINK�ER SVSTEM STATE / LIC. �
Compensation provisions of the Labor Code,you must forth- yyATER HEATER LIGENSE NO. /��l�Z CLASS �-s3
with comply with such provisions or this permit shall 6e DISTRICT NO. PR ESSED BV
deemed revoked. GAS SYSTEM OUTLETS /�� �� �� )
LICENSED CONTR.4CTOR5 DECLARATION OUTLETS OVER /� �7\,� WJA�V6�
t hereby effirm that I am licensed under provisions of Chapter 5 £R 5�'ST M
9 (commertcing with Section 7000)nf Division 3 of the Busi- FINAL VALIOATION
ness and Professions Code,and my license is�n full force xnd � �d � � � DATE 3 � O 3
effect.
a
FINAL �
License Number Lic.Class . 9 V „�`
Contractor Dste
� 1 am exempt from the licensing reyuiremeots a5!am a Plan check fee
]icensed architect or a registered professional engineer pLUM61NG PERMIT ISSUING FEE$ 50
acting in my professional capacity(Section 7051, Bus-
iness and Nrofessions Code). TOTAL FEE S� �
Lic.or Reg.No. Date Plan check app�icent �� 7 7�2�A
HOME OWNER-BUILDER DECLARATION Name �1• • • • •5
I hereby affirm thxt I am exempt from the Contractor's Adtlress � • • � b.S O
License Law fnr the following reason (Section.9031.5,Basi- Ctty Tel.Na.
ness and Protessions Code): • • ° � b�Jr,�c=i
� I,as owner of the property,am exclusively canLracting
with licensed contraetors to consEruct the project ��4�'—�.�
(Seetion 7044,Business a+�d Professiarts Code).
CONSTRUCTION LF;NDING AGENCY .
I hereby aff7rm that there is a cons[ruc[ion lending agency
fot the performance of the work for which this permit is .
iseuad(9nc.3fi97.Cir.C.).
IsmMtin'9 R7ttito-
i,��dee's.QdMtear -
I certiCy that I have read this applica[ion and sEate that the
above information is correct.I agree to comD�Y K'�th all Couniy SLE REVERSL FOR EXPLANATOAY LANGUAGF.
ordin� ces and State laws regulatirtg Plumb�ng, and here6y
au ei e representatives of this County to entcr upon the �
a uve- ent�prope y(or inspection purposeb,
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LNDERSLABWORK .
ROUGH PWtd91NG .�___.�,��..�.�_._._�. - I l. . _*�� Y•_�1 aci[.�c ;t f,uea i�.Cc�i;rsctnr's
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ASPIPI� i � � /;:;: ,. :p;,�� [ ( r:'- �! -J .?t[4' Cif;' Cr CUL'1:ty
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