HomeMy WebLinkAbout5651AOMPE"SAT'°" pECIARATI°"
APPLICATION FOR PLUMBING PERMIT
it herebyaffirm that I have a certificate of consenNo self
insure, or a certificate of Workers' Compensation t uran
76g667q a,�^,+_t-r'
GE 817 {REV LDA(.6T}
�.
or a certified co thereat (See. 3800,'[ �-.'C���,COUNTY
/
OF LOS ANGELES
...
.-. BUILDING AND SAFETY
Policy N ' Co �panti4
Certifiedcopy reb furnished
- .
...
APPLICANT TO IN PRINT OR TYPE) -,
{
- BUILDING
ASS /7G�
Certified copy is filed With the.FOR
county building rnspeq
-
tion department.
P
OR ITEM
NUMBER TE @' FEE
l lil' .Kim-"•'�
,.Dote A li ant
pp 5
WATER CLC�SETURE
NEAREST
-'. - CERTIFICATE OF. EXEMPTION FROM WORKERS' '
_
,'. - BATH TUB
CROSS ST.-
- -`COMPENSATION INSURANCE•
-
OWNER,
- (This seetfon need not be completed If the work Involved by
SHOWER
,
;the parmit Is for ane hundred dollars ($100) or lass.)LAVATORY
- •
MAIL
ADDRESS
I eertify that in the performance of the work for which this
permit islssued, J shall not employ any person in any manner
SINK`. '`
`' CITY.. TEL. O.
-so os to become subject to the Workers' Compensation Lows
DISHWASHER
CONTRACT�...
:. Date Applicant -:
CLOTHES WASHER -'ADDRESS
NOTICE TO APPLICANT; If, after: making this Certificate ofi
Exemption, you should become subject to the Workers'
SWIMMING POOL RECEPTOR,
CITY - - TEL.
ILICENSFWATERHEATER
. Compensation provisions of the labor Code, you must forth-
LAWN SPRINKLER SYSTEM
.with comply with such provisions or this permit shall be
STATE -. -3 UC.
.deemed revoked,
NO. J CLASS '-
LICENSED CONTRACTORS DECLARATION
Y
DISTRICT NO,D
BY
- I hereby affirgm that I am licensed under provisions of Chapter 9
GAS SYSTEM OUTLE
0-
(commencing with Section 70W of Division 3 of the Business
OUTLETS OVER -T5
OLiTt
�'..
- and Professions Code,. and y license is in full force and effect.
5 PER SYSTEM
- FINALS
VALIDATION
V
.J
- License Number -1//-6d Class
Oc
•�
FINAL
BY
Contracta�—�,S Date ..7
-F am exempt under Set.
B.sP.c. for this reason
Plan check fee _
Dote'
PLUMBING PERMIT. ISSUING FEE 8SQ
IC
--Signoture
_
' TOTAL FEE
d
Plan check applicant
- SINGLE FAMILY
'
- HOME OWNER -BUILDER DECLARATION
Name '-
1 hereby affirm that I am exempt from the Contractor's license
5 6
Law for the following reason (Section 7037,5,: Business and
Address
- -
j
Code); - - -
City- ' Tel. No.
}i i e a 's'a Jr•
1
{P'r'ofessions
❑
1, as owner of the property, will do the work and the
�,.� 2 2. 5
1 4 Q
structure is not intended or offered for stile (le Section
�-
70", Business and Professions Code). -
,. 2 2 5
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for
�, Q9•) �i � S 4,
-
- the performance of the work for which this permit is issued,.
(Sec. 3097, Civ, C.). :-
-
- Lenders Name-
- Lender's Address
I certify that.t have read thisapplication and state that the
above information is correct. t agree to comply with all County
ordinances and State lows regulating Plumbing, and hereby
- authorize representatives of this County toenter upon the'
above-mentioned property for inspection purposes.SEE
REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permiltee - .Date - •
-' `"' .-'
- - -
APPROVALS
DATE INSPECTOR—. SIGNATURE
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST
UTILITY CO. NOTIFIEC)
FINAL
INDUSTRIAL
WASTE APPROVAL
INSPECTOR'S NOTES :* CLWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from We Contractor's
License Low for the following reason (Section 7030.6,
-Business and Professions Code); Any city or county which
requires a permit to construct, after, Improve, demolish,
or repair any structure, prior to its Issuance, ofso re.
quires the applicant for such permit to file a signed state-
ment that,he,.Is licensed pursuant to the provisions of the
Contractor's License Low (Chapter 9 j (commencing with
Section 7000) of Division 3 of. the Business iond Prof s-
slons Code) or that he Is exempt therefrom,and the basis
for -the alleged exemption. Any violation of Section
703 t.5 by any applicant foro permit subtects the Gppll-
corif to a civil penalty of not more fhan-five hundred
dollars ($500).:
❑ 1, as owner of the property will do the work, and
the structure is not Intended. or offered for sale.