HomeMy WebLinkAbout1734A (10) � .__ , ... . ' .."'. . ___.........._.__.._. . . . ..
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WORICGRS'COMPENSATION DECLARATION �s�ss�w �
� I hereby ar��m �hat � he�e a'certificate o��0�5��fa sz�< <g.,.c=.., A P P L I C AT I O N FO R P L U M B I N G P E R M IT
�� insure,or a certificate o}Workers'Compensation Insurance,or . . . , �
' a certified copy[hereof(Sec.3800,Lab. �
- COUNTY OF LOS ANGELES BUILDING AND SAFETY
. Policy No. Company � -
� � Certified copy is hereby fumished. - FOR APPLICANT TO FI LL IN(PRINT OR TYPB) BUILDING N/��y
� ADORESS� J(Q(J
� 'eltified copy is fiied with t county building insprction NUMBER FIXTURE OR ITEM / FEE
` ertment. LOCALITV
Det9�.�.�� �caat / W/{TER CLOSET� NEAAEST .
BATH TUe CROSS ST. �
�� CERTIFICATE OF EXE. TION FROM WORKERS'
COMPENSATIONINSURANCE SHOWER OWNER
� (This secUon need not be completed it the work involved LAVATORV rota1L
�. by the permit is tor one hundred dotlars (5100)ar IeseJ ADDRESS _ QD
SINK CITV TEL.NO.
I certify that in thc performance ot the work for�vhich this DISHwASHER �
� permit is issued.I shall not employ any persan In ony manner CONTRACTOR
� so as to become subject to the Workers'Compensation La�vs. CLOTHES WASHER �
ADDRESS O
Dete Appllcsnt SWIMMING POOL RECEPTOR � � (� U
NOTICfi TO AYYLICANT:If,after making this Certificate of CITV TEL.NO. p1
Ezemption, you should become subjtct to tlie Workers' LAWN SPRINKLER SYSTEM STA E LIC. t�17
' Compensation provisions of ihe Labor Code,you must forth- WATER HEATER LICENSE NO. CLASS - 3 z
witf� comply with such provisions or this permit shall be DISTRICT NO. PR ESSEO BV�
deemed revoked. / GAS SVSTEM OUTLETS i} (�
LICENSEDCONTRACTORSDECLARATION DUTLETSOVER (� �"°'i''��
1 hereby affirm that I am ticensed under yrovisions of ChaDter 6 P R SVSTE �
� 9 (commencing with Section 7000)of�ivision 3 of the Busi- /� FINAI
ness and Professions Code,and my license ls in fWt force nnd / / r�' "� - d U DATE 3 YALIDATION
eftect. �
1.{ FINAL
Lice N be('��Y.��Lic.Cluss�� BV
�� ' ntract r�#y�_ Dete��6—8y . .
� I am exempt trom the licensing requirements as I am a Plan ChCC{c fee .
� Iicensed architect or a registered professionai engineer pLUMBING PERMIT iSSUING FEE S �(! �
� acting in my professionel capacity (SecNon 7051,Bus-
ine5s and PrcTfe55ion5 COde). TOTAI.FEE /(f .
; Lic.or Reg.No. Date Plan check appliunt �
HOIv1E OWNER-BUILDER DECLARATION Name . , - . ��7�4 a
1 hereby affirm that I am exempt from the Contractor's Add�e�a
' License Law for the following reason (Section.703t.5.Busi- Clty Tel.No. ����� � � �5
ness and Protessions Code): �) • +2 Q 5�
� � I,as owner ot the property,am exclusively contracting � . '
- wiih licensed contractors to consVuct the projeCt •2 0,5 p c=i -
(Section 7044,Business and Professions Code). '
CONSTRUCTION LSND[NC AGGNCY O�O�l—8 Z
. I hereby affirm that there is a construction lending agency
� For the pn�formance of the work fo� which this permit is . .
� issued(Sec.3097,Civ.C.). �
�� Lender's Name
. LendePs Address
I certify that I have read this application and s[ate that the .
above information is correct.1 agree to comply with all County SEE REVERSC,FOR EXYLANATORY LANGUAGE
� ordinances and State laws regulating Plumbing, and hareby .
. authorize representatives of this County to enter upon [he
e-mentioned pro rrty tor inspection purposes. -
i /tirr.!'�� ��-�-�n_LI�� . . .
' ignature uf Pe mittee llate
, APPROVALS OATE INSPECiOR551GNATURE „��� INSPECTOR'S�!OTES O11�i�CI:-CUILULR I)iCLtIP.ATION ��
, UN�ERSLA8590RK � - � � '
� ROUGH P�UMeING • 1 Lcreb}:a(finn thst[am r�cmpt fcom tlic Contractor'S ,
Licence�1�n� for lhe�Pullut�'in^_teason(Szrfiort 7031.5. ,
GASPIPING ' � �(11f2 ( �(f�u',L{`-� ' R1r.rfr:c,ss citd ProjeSsiotts CadeJ: :111}' eif�' or eotrr.tv
� GAS VENT ' � . i�•I�icl: requirer r. permir ta cwicmrer, alter, impro�•e. ,
HOT WA7[F HEATER den:n7ish. or repair crty�sln�r(rve,pri0r to its is.tuaRCC,
?LU�1oiNG FlXTURES � � T ' , � clso reqiiires lf�e of�r�:icm�t for si:cl� permit fo file a
� �.ri���ed.tlatem.crtr thr.r hr is firenreA yiirsr�nt fo !!re
F GIaSTEST (� �a QLt'• , . prorisiw�.c of llrc ('orttrarinr's Limrtse Lcw(Cllaptcr 9
UTILITV CO.NOTIFIEO� ��'r»�t�nc�t^in,^ �i.i!/; $���fir�r� 7000J of Dii'ici��t 3 Of 71�C
� P��siii¢cs ar.:l Profrssioru CodeJ or Ifta( !te is exe�ttpt
thcrefrorri cr�d fhc baris for Ifie afkged exemption..frrr
FINnL �'�p��, �y G�3�' "� ' � riofafior.of Scr7iori?q31.5 Ll'anp nq^licant fora pcnnit
�+���ll/��e � � . subl"ets 7J�e ayplicmtt to a rirr!/�ermlty of��af�nore tfiarr
iNDUSTRIA� � ' „ firrL:m:lreddn!lars(SSGR/.:
`NASTE APPROVAL • . O I.85 o��'I`�C:o(tllc��(opert}'�till da tltc��'ofk,an�
, thc x[nictum is not i�tcrd:d or ofPcrcd far salc.
. . � . .. . . (Sec 70-1-1. P,ucir.ess end Projetsior,s Code: Tlie Cou•
• , , � �� -• � � 7r::;�tor'3 l.iceirse I.a�r ducs r:ot cppl}� to an o�r��er of
� . � � . - - �� , prn;crt}��-�t�ho b��il�h or inrprores fi;crc<�ir,arrd�cho does
. - i.. � - � surtr �:orR hin:�,^!f proridcd tLa� s:icL in:�irorcrnenes
� `� ' . .- � .. . � . . : nr� no7 ir,tena+rd or offrred fnr sale. !I. Ao«�ercr. 1hc
� � . , h:aiidim,: or irnproren:c�u is solA �cithi�i oue ��rar of
. � co�r.ple�inrr. tl�e own��-bui(d✓ �ci!! F,are 7he burden
. _ . of prm�i+rg �1;at he diA itot b�iild or impro�r jor rhe
purpase nf Sa(c.l
- I arr.escmpt tmdcr Scc. ,
�P,F;I'.C.fur d�is rensou .
Ustr
Oirncr '
, G i�; ; �INSPECTOR'S NOTES �
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