HomeMy WebLinkAbout5651A (17)OMPE"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
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or a certified co thereat (See. 3800,'L �-.'C���,COUNTY
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OF LOS ANGELES
i
.-. BUILDING AND SAFETY
Policy N ' Co �panti4
Certifiedcopy reb furnished
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APPLICANT TO FILL IN PRINT OR TYPE) �-,
{
- BUILDING
ASS /7G�
Certified copy is filed With the.FOR
county building rnspeq
-
tion department.
P
NUMBER OR ITEM @' FEE
l lil'
,.Dote A li ant
pp 5
WATER CLGSETURE
NEAREST
-'. - CERTIFICATE OF. EXEMPTION FROM WORKERS' '
_
,'. - BATH TUB
CROSS ST.-
- - COMPENSATION INSURANCE•
-
OWNER
- tionneed not be completed If the work Involved by
SHOWER
91111
;the parmit Is for ane hundred dollars ($100) or lass.)
- LAVATORYMAIL
- •
ADDRESS
'i certify 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 tows,DISHWASHER
CONTRACT
:. Date Applicant -:
CLOTHES WASHER -'
ADDRESS Q? =7:/NOTICE
TO APPLICANT; if, after: making this Certificate of
Exemption, you should become subject to the Workers'
SWIMMING POOL RECEPTOR'
Y - -
CITTEL. N
. Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
�` o
.with comply with such provisions or this permit shall be
STATE -. SUC.
3
.deemed revoked, -..,.- . s,,- .:
WATERHEATER
"" LICENSE NO. J CLASS '-
LICENSED CONTRACTORS DECLARATION
DISTRICT NO,
BY
- 1 hereby affirm that I am licensed under provisions of Chapter 9
GAS OUTLETS
\ fPRORSED
(commencingwith Section 70DOof Division 3 of the Business
SYSTESTEM
OLiTI ETS OVER -T5
CL
and Professions Code,. and y license is in full force and effect.
-
S PER SY$7EM
FINALS
VALIDATION
.J00
- License Number�tk. Classcx�wS:h
-
II,
V
•Date
'.',
FINAL
BY
G[
Contracta�—�,S ..7
E-F am exempt under Set.
V
-,. -
B.$P-C. for this reason
plan check fee_
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Dote'
PLUMBING PERMIT. ISSUING FEE $ '^�Q
--Signoture
'.' TOTAL FEE
d �-
Plon check applicant
-SINGLE FAMILY
'
- HOME OWNER -BUILDER DECLARATION
Noma
1 hereby affirm that I am exempt from the Contractor's license
5 6 5 t A
Low for the following reason (Section 7037,5,: Business and
Address
- -
j
Code); - - -
City-' Tel. No.
}i i e a 's'a Jr'
1
Cl'ofessions
1, as owner of the property, will do the work and the
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structure is not intended or offered for stile (le Section
`
70", Business and Professions Code). -
.. r a.Y It 2 2 5
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for
�, Q9•) 1 � 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 00- NOTIFIEC)
J94,rt- Jrf rvj 1
a—InIS6
FINAL &t." on 5—.1
INDUSTRIAL
WASTE APPROVAL
INSPECTOR'S NOTES :n OWNER -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, also 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 thersfrcm>and the basis
for -the alleged exemption. Any violation of Section
703 t.5 by -any applicant foro permit subtects the Gpph-
conf to a civil penalty of not more than -five hundred
dollars ($500).:
❑ 1, as owner of the property will do the work, and
the structure is not Intended. or offered for sale.