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HomeMy WebLinkAbout8604A (20)M ENSATI N DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that i 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 No, 3032l11i1pmpanyOr- AmPri[+anCertified �.. copy is hereby furnished. ©FOR Certified copy is filed with the county building fnspec- APPLICANT.TO FILL IN (PRINT OR TYPE). - BUILDING. ADDRESS 21010 Chiriping SlOaiiow Rd. - - flon department. - .- - -. "-NUMBER FIXTURE OR ITEM �- - TEE LOCALITY ' B -4-B3'... Leaverton-'Beck;. '- WATER CLOSET - - gar .. ..�.. ', - _ �.. -:3 Date Appli4ant- NEAREST ! - CERTIFICATE OF EXEMPTION FROM WORKERS' n ,9 - :. - PATH TUB `. j- CROSS $7. - COMPENSATION SHOWER OWNER pclriderosS t Homes (This section need of e completed If theCwork Involved by _., thepermit is 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 �. CONTRACTOg,e,"aveiton-Beck, Inc.. .. Date Applicant - CLOTHES WASHER ADDRESS 16721 Hale NOTICE TO APPLICANT: if, after making this CertifkCie of -. SWIMMING POOL RECEPTOR Exemption,. you: should become subject to the Workers' - - CITY f ire 92714 TE'- NO -863-1166 Compensation provisions of the Labor Code, you trust forth- you LAWN SPRINKLER SYSTEM - - rV . with comply with such provisions or this shall be - STATE191969 - LIC. C36 deemed revoked. - , : WATER HEATER - �;,': LICENSE NO. CLASS - LICENSED' CONTRACTORS: DECLARATION - GAS SYSTEM OUTLETS DISTRICT NO.- P CESSED BY 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 4713f; DATE u 4- FIN FINK . - - Contractor I- �raPikyPTt011-itl f-KDot. A -4-Q3, BY :--0 - 1 am exempt. under' Sec.- - B.&P.0 for this reason Plan check fee Dote: �.�.. . PLUMBING PERMIT ISSUING FEE $ -Signature .-, - , .. TOTAL FEE .. i7a .1-0 - Pion check applicant _ $ b U 4 %) SINGLE FAMILY ' - HOME OWNER -BUILDER DECLARATION Name - '- -- - .. - ,,,s .• • • , " I hereby affirm that i'm exem from the Contractor's License Law fpr the followingreason Section 7031.5, Business a l res Address - i • 1 Q a 5 : i _nd Professions Code): City Tel. No - - I, will work - I• • , �.d �' os owner of the property, do the and the - structure is not intended or offered for sale (Section/ $ 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 have 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 SI-AB WORKA tl I- 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 - I hereby affirm 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# thaChe Is licensed pursuant to the provisions of the - ContractorLicense Low (Chapter. 9•�(commencing with Section, 7600) of pivision.3 of the business and Pro(es- .. - slams 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 'parialty=of not more dhan-five hundred dollars ($500).: ❑ I, as owner of the properly will dothe work, and the structure is not Intended or offered for sale,