HomeMy WebLinkAbout0771A (4) �.woeKeRscoM�NSATioNoeaaaAnoN APPLICATION FOR PLUMBING PERMIT.
I hereby,.affirm�that I have a certi(i�ate of tonseni io self in• -�A�,A�Pw<ie� f�
sure,or a Cerfificate of Wo�kers'Compensafion�lnsuronce,or o ��CE Bq�REV.BiB6) � � .- .. � 11 I .
tac�ified copy ihereof(Sac.3800,Lob.C.��� . � � LJ
Policy No.73WG00504,�Q��nyNATI0N47IDE ' COUNiY OF LOS ANGELES DEPT.OP PUBIIC WORKS
� �.Cerii(ied copY is here6y furnishad.� .. . � • ' �. � 42578 �
� f":} Cerlifiad copy is filad wifh the counfy building inspeclion FOR AP7�ICANT TO FllL W(PRINT OR TYPE� BUiLDWG EAST BRYN A�YN wAY
A��RESS
l.d dlppfimenl. . NUMBER FIXTURE OR ITEM @ FEE �p�AIITY� � � B� .
NEW PLUMBING 3 . wnrea aoser iraner> 6 18
� Date 9�1"$8 ApplicoM CROSSSST. (�,�D [�V$: .
�� CERTIFlCATE OF EXEMPTION FROM WORKERS' � - z BATM TUB . lZ
�, � COMPENSATION INSURANCE �" SHOWER � 12 ow"ER � RAMALEA �LIMITED
� (Thi�sadton n��d nof b�complsf�d H Ih�work inrolwd by . . htai� � � .
}b�pnmll ls for on�hundnd dolion(SI00)or lus.) � IAVATORY aDDRE55 .
1 certify iha�in the performance of Ihe work for which ihis per- SiNK � -
mit is issoed,I sholl not employ any person in ony manner so 2 � � 12 OiV COSTA MESA iEL.NO.$SO^lOOl
�os to become subjed to Ihe Workers'Compensotion lows. DISHWASHER �
. . I 6 CONTRACSO
'�, Dafe ' - �Applicont CLOTHES WASHER �7 ADDRE55 21(�1 S. DUPONT DRIVE
. I�E i0 APPLICANT:�f,oGer rr�aki�g this CP�iifi�n�P.af Ez- SWIMMING FOOI RECEPTOR
�lon,you should bemme subject to the Workers'Compem Citt TEL NO.
su��on provisians of Ihe Lobor Code,you must lorlhwilh comp- � W,WN SPRINKLER SYSTEM ��IEM 937-3972
ly with such prov�sions or this permit shall be deemed reook- � Srnre uC.
ed. � - � � . 1 WATER HEATER ' 6 LICENSE NO-4Z61O ' C1A55 —
� � LICENSED CONTRACTORS DECLARATION DISTRIC7 NO. PROCESSED Bv
'" I hereby oHirm Ihaf I om li�ensed onder provisions o1 Chopter � GAS SYSTEM qUiLEiS d
9(cammencing with Section 7000)of Divisian 3 of Ihe Business OUTlETS OVER
1 5 PER SYSTEM 1 50
� fea,P�ofessions Code,ond my license is in(ull force and ef- DA E� � ALIDATION >
O
LicenseNumber 62Fi109 _LiaCbss C-3h . . . p
FINAI -
Controc�o� NEW PLUMBIN6 Dote 8-31-88 gY �'Q 7 7•� � O
r
� I am exempt under Sec. k� • � � °5 W
a
e.av.c�o,ih�s rea:o� Plan check fee ` I •1 1 4 C 0 x
� - - - - - --- Dafe: � PLUMBING PERMIT ISSUING FEE E ld SO ° ° � � 4,f�C;�
Signature . � 707AL FEE 11 D a� �_��5 �
- SINGLE FAMILY .
HOME OWNER-BUIIDER DECLARAT�ON Plan check applimnr � '
, I hereby affirm thar I am exempt from the Comrac�or's License Name � � - � '
'� r.for the following reoson(Section 7031.5, Business and ' � � � �
essions Cade): . . . Address .
aI,as owner of 1he property,will do Ihe work ond 1he City Tel.No. ' �
� shuUore is not intended or offered for sale(Section 7044, � . . .
� � � �Business ond Professions Code). _� : � ► �
' � . CONSTRUCTION 1EN01NG AGENCY � � � � . � � . � -
' I here6y affirm ihat�here is a conshuclion lending agenty for �
Ihe performance of Ihe work for which�his permil is issued �-� - � � �
(Set.3097,Civ.C.). . . . . � .
lender's Name . �
lender's Address � � � �
� I certify thar I have read Ihis applicorion and state�hat the ' � -�
obove information is corracL I agree to comply with oll Counry �
ordinonces ond Slote lows reguloting Plumbing,ond bereby - - �- - �
outhorize represento�ives of this County io enter upon Ihe . -
� ob ve•me �ionad propa��y fo�inspeclion purposes. � � . � � �
� �� 8�,�l� SEE REVERSE FOR EXPLANATORY LANGUAGE
� Signature of Permitfee � � Date . � �
APPFOVALS OATE INSPECTOR'SSIGNATURE �NSPECTOR'S NOTES - �1NNER BUILDER DECLARATION,. �
UNOERSLA6WOflK ' I F19f9Dy 9MItlt1�YIM �AT exampt from tha ContrsCtoYs
ROUGH PWA�BING LJC6MB�LeW'10f tfN�WIOWIf1Q lB9Ed1 (SeCt(on 70,?1.5,
8uslness and Proiessbns Code). Any dty or county
cnsviaiNc - - - - - which requlres a permlf to consfrucl, aftor, improve,
cnsver+T demollsh or repalr any struciure.prlor to Its Issuance.
HOT wnren nenTea � , _ also requires fhe applicant forsuch permft to file a s/gned
PwusiNc F�xTURes statement ihat he Is Ilcensed pursuant ro the provislons
of the Contractor's License Caw(Chapfer 9(commencing
cas resr wlfh Sectlon 7000)ol Dlviston 3 0l the Buslness and Fro-
unun co.NonFieo lessions CodeJ or that he Is exempi therelrom and the
, basls lor the a!leged exemptkn.Any vfolatlon of Section
FiNA� . . � 7031.5 by any 8pplicent lOr a pBrroft sU6(6Cts the eppli-
�nEer on�.ant cant to a cJvJl penalfY o1 not more than five hundreU
dollars(5500).:
INDUSTFIA4 . � . , . ❑�,as ownar of th8 OroWrty wip do the work.entl the
WASTE APPROVAL� � �' ' � '- ' ' �84NCtUfB IB IfOt II1SBfH�BA M OMBf6C IM 9818.
(Sec.7044,Buslness and Pro/esslons Code:7De Cont�ac-
. ror's Ucense Law does not apply to art owner ol prooerty
who Durlds or lmproves the�eon,antl who does sui +rk
hlmself provkfed that such lmprovements are not�,..,nd-
ed or offered�or safe.If,howeve+,tbe building or Im-
. . . ._ . _.::... � p�ovement Is sold wlthhr one year o�completlon, the
owner-6uiJder wlll have the twrden o�proving thet he dld
nof build or improre!or the purpose of sale.)
I am exempt under Sec.
B 8 P.C.for thla reason
, Date
Owner
INSPECTOR'S NOTES
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