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HomeMy WebLinkAbout8604AM ENSATI N oECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that t have a :certificate of consent to self 76A667A. - Insure, or a certificate of Workers' Compensation Insurance, CE 817 (REV. 10/81), or a certified copy thereof (Sec. 3800, tab, C.) - COUNTY OF. LOS ANGELES .... BUILDING AND SAFETY�� Policy Nam-92B1ibmPanY...i^,r_ Amarinan _ C' Certified copy is hereby furnished. ©FOR Certified copy is filed with the county building insoec- APPLICANT.TO FILLIN(PRINTORTYPE). - BUILDING. ADDRESS 21010 Chiriping SlOairow Rd. - - flon department. - .- - -. "-NUMBER ',.. FIXTURE OR ITEM �- - TEE LOCALITY �B-4-83'... Leaverton-'Beck;. '- WATER CLOSET - - 3 gar .. ..�.. ', - _ �.. Date Appli4ant- NEAREST ! - CERTIFICATE OF EXEMPTION FROM WORKERS' ;3 - :. - PATH TUB `. j- CROSS $7. - COMPENSATION SHOWER OWNER Ponder'osi Homes (This section need of e completed If theCwork Involved by _., theisis for one hundred dollars ($100) or less.) - LAVATORY - "" ADDRESS --�P - 8 OX -2340 - 1 certify that in the performance ofthe work for which this _ - -! - permit is issued, 1 shallnot employ any person in any manner' SINK -" �,. CITY TEL NO.` 1 6 — come subject to the Workers' Compensation Laws, - so as io,be, DISHWASHER �. CONTRAC9 LdaveIton—Beck, Inc.. .. Date "Applicant - CLOTHES WASHER ADDRESS 16721 H310. NOTICE TO APPLICANT: if, after making this Certificate of SWIMMING POOL RECEPTOR Exemption; you: should become subject to the Workers' - - CITY frV ire 92714 TE'- NO -863-1160 Compensation provisions of the Labor Code, you trust forth- LAWN SPRINKLER SYSTEM - - . with comply with such provisions or this permit shall be - STATE' : 191969 - LIC. C36 deemed revoked. - , : WATER HEATER - �;,': LICENSE NO. CLASS - 'LICENSED' CONTRACTORS: DECLARATION - GAS SYSTEM OUTLETS DISTRICT NO.- P CESSED BV I hereby affirm that I am licensed under provisions of Chapter 9 .-� (commencing with Section 7000) of Division 3 of the Business - and Professions Code, and my license is In full forte and effect. - OUTLETSOVER 5 PER SYSTEM - - FINAL VALIDATION License Number 191963 Ga. Class f'3f; DATE 04 FIN . - - Contractor I- �raPikyPTt7011-i tr f-KDot. 8-4-Q3, 'BY --0 - 1 am exempt. under' Sec.- - e.&P.0 for this reason Pion check fee - Dote: �.�.. <PLUMBING PERMIT ISSUING FEE $ Signature ... TOTAL FEE - Pion check applicant _ $ 6 U 4 A SINGLE FAMILY ' - HOME OWNER -BUILDER DECLARATION Name - '- -- - .. - ,,,s .• • • , " there affirm that i'm exem from the Contractor's License - Law fpr the followingreason Section 7031.5, Business and l Address - 1 Q. - i • Q 5 0 Professions Code): City Tel. No - - I, will work - 05 I• • , 0..d os owner of the property, do the and the - structure is not intended or offered for sale (Section/ Q $ 1 i .7 8-3- 7044,' Business and Professions Code). - - - - CONSTRUCTION LENDING AGENCY, I hereby affirm that there is o construction tending agency. for- - the performanceofthe Work for which this. permit is issued .(Sec. 3097, Civ. C. - : ). ., - tender's Norm Lender's Address I certify that I nave road this application and state That the above Information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize repro ntatives of this County to enter upon ,the- ob menti property for inspersion p o(sLeJs SEE REVERSE FOR EXPLANATORY, LANGUAGE Signature of. Permittee - Dafe APPROVALS 'DATE " .INSPECTOR'S SIGNATURE UNDER SLAB WORK - ROUGH PLUMBING - GAS PIPING GAS VENT HOT WATER HEATER PLUMBING FIXTURES .. GAS TEST UTILITY CO. NOTIFIED - FINAL f Gntar on. yraat INDUSTRIAL - WASTE APPROVAL INSPECTOR'S NOTES' - - - ' OWNER' -BUILDER DECLARATION - r. I hereby offirm that I am exempt from"the Contractor's License Low for the following -reason' (Section 7031.5, .. -. _ Business and Professions Code): Any city or county `which _ - requires a permit to construct, alter, improve, demolish,. - or repair.cny structure, prior to its Issuance, also re- - _. .. .. .. - quires the applicant for such permit to file c signed state- - men# fhaChe Is licensed pursuant to the provisions of the - - Conhactor's License Low (Chapter. 9•�(commencing with Section, 7600) of pivislon.3 of the business and Proles- `. .. - sJons Code) or that he Is exempt therefrom and the basis -- - - - for the alleged exemption. Any, violation of Section _ - 7031,5 by any applicant fora permit subjects the appli- cant to a civil penalty of not more dhan-five hundred dollars ($500).: +., - ❑ I, as owner of the property will do the work, and - - . the structure is not Intended or offered for sale,