HomeMy WebLinkAbout1649A (23) 'lh'ORKfRS'COMPENSATION DECLARATION APPLICATION�FOR PLUMBING PERMIT f7
� I hareby affirm thal I have a cerfificole of conceN to self 20�0028 OPW 6/97 C i
ins�re,or o cen'rf�cate of Workeri Compensofio�Inwrpnce, 78A867A ��
o�aisretiad copy rheroof�5ec.3800,Lob.C.) ' COUNTY OF LOS ANf3ELES DEPT.OF PUBLIC WORKS ��
PQolicy tJo.��Company
Certified xopy Is hereby furnished.
� aFOR APPIIGNT TO FILL IN(PRINT OR TYPE) EUiLWNG
Certified copy is fi�ed wi�h the county buildieg inspsc- A��u �
tio�depurtmenf. NUMBER fIxTUREORITEM � FEE ��11TY �
W ATER CIOSFT �+ /1
Da�e AppliGanl CqpSgST. .JyLh (.i� l..YpS,rJ1 � �� oi,t�
�� CERTIFICATf OF EXEMVTION FROM WORKERS' BAT}i TUB
COMPENSATION INSURANCE
(Thls s�dlon e��d nof b�compbl�d 111h�work Involwd 6y �OWER �� � 0.Y'v�CS
'�, 1M p�rmll is ior on�hundnd dollan(f100)or b■s.) V,v�iOkr AODRE55 � • O Nt
'�� I cerfily that In the performance of the work for whlch fhis
� psrmif It iuusd,1 sholl not employ on peno�In a monner SINK CITY � r. TEL,NO'�(��—
ao m to beeoms�ubjec�fo rhs Wo Comp on laws. D�SHWASHER �
COMRACfOR
Date epplico CIOTIiES WASNER A��
NOTICE TO APoI.ICANT: li, afror makinp thi�CerHficare of Swinv�ur�a0a ReCEviqt
E■amptlon, you �hould baeoma �ubjact to iha Workars' �iTY . TE� nro
Compenwtim�proviaiorn of the Labor Code,you musl fwfh• UWNSPRINKLERSVSTEM
� with comply with tuch provlaions or thi� permtr shall be SipTE uC,
deemed rovoked. w�iea Neni�t �KE�SE NO. C�w55
UCENSED CONTRACTORS DECIARATION D�SiR�CT NO. PROCESSED BY
' I harcby cff'am llq�I am Ilcemsd under provi�ions of CFwpfer 9 GAS SYSTEM WTLETS f O ��
(commencinp with Section 700D)of Divi�lon 3 of�he Busineas WTiFTSOVER
� ond Fofeaaiorw Code,ond my liceme is in ful�force and effect. 5 PER 5v5iEM PINAL �^� VAIIDATIGN O
DATE `�
Litenae Number Lia Closs V
, FINAL �
ConNocbr Date BY
' O
❑ I om e.empi under Sec. (O �� �t� �—2 3-Q Q W
B.BP.C.for this reawn n-'
Plon check fee ► �L�p, @y��,s�Cj p , z
� ���- PLUMBING PERMIT ISSUING fEE S t O /U n
Signaturo . ' r "
�fJ.,� •-
TOTAL FEE
- — , .' .�,�i.
� ���- Plan check app�imnt
' SINGIE FAMIIY �1 6 4 9 A
HOME OWNER-BUILDER DECLARATION Noma
1 hereby offirm ihat I om evempt from iha CoNracfor's License qddress �� � � ° �`�
, Low for tF�e following reoson(Section 7031.5,Businass and .
, Rofessions Code): Ciy Tel.No. � -• � � �J��
. ❑ I,os owner of the properfy,will do the work and 1he a � � �rJ��
s�ructure is not inronded or offe�ed fo�sale(Secrion , �
� 7044,Business ond Mofeuions Code). �9.� 9—&�S
CONSTRUCTION LENDING AGENCY
� I hereby affirm thol Fhere is a cons�ruc�ion lending oqency for
� Ihe performonce of the work for which this permit is issued
(Sec.3097.Civ.C.).
Lander's Nome
Lender's Address
' I certify thai I have read this opp�ication ond siata�hoi rhe ►
obove informvlion is correcr.1 agree to comply wi�h oll Couniy
� ordinonces and S�ate laws requloting Plumbing,and hereby
aW 'e repre�enlat'ves of this County�o en�ar upon �he
� o ve• entioned rfy fw inspedlon purposes.
/������j SEE REVERSE FOR EXPIANATORY LANGUAGE
�� b
`'�•Signature of Permi tee Do�e
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;,vpRpV:,;S CATE �'�SPECTOR'S SIGNATURE - INSP:CTOR'S nOTES Oi;vNE�-6U!LD_R DEC:I..nRC.i;pM '�
UrJDE25lA3tvORK 1 hereby afFvm�hot I a�er.empr':ro��t� �Curarr._�r'>
ROL'GN FW".:6I`7G �'; - . . - ^ lleensc Lev. for Ihe fnllewing re.aso.^.�(Scction 703i 5.
G�SP�FNG ' � � � �- — � � � - DusinessandProfecsionzCod-.'.Artyc:tyorcour.tywF�ch
GAS YENT � �, `r . requi�cs u permlf to cons!rucl,a(fer.I,mprovc:dc.^+of�s`�.
NOt WATER H°ATER o�repvir any slrucfure, priar �o iis Issuon�e, ofso re�
- � quiree fhc applimnt lor zoch permil fo fIc o vgned s!c�e-
� oWr;,gIN„Fi%;U6FS- � � " '� menl Ihor hels I�censedpursuont tn.iMr provuicns o!}ho
� GASTeS1 ' ' Confroctor's Cicense law(Cho�rer 9(rommenc�nq�•�irh
� � Section 70J0)of Oivision 3 oF fhe Ctusiness and Profes-
U�ILI?Y CO.t�OTIFIEO - -
, , . , , � . sions Cod�)or than c��s exempf lherefram and�he b^sis
� �" f c7 � � - - for +he alleged errnption Any viofonon oi SPctian
F�^:n� �"" - '�r•nlcr _}�on(- I . . - _ . . 7031.5 by anY applicant(or a permil sub!c:h fhc a�pli�
� tcnl to a eivil.penalty o�no1 nore Ihon five hund�ed
' - ... . dolfc�rs(5500).:
!r;pUST:J:.I ...,,t� :.,�I:as ov+r.c-�c`the proper,y ir�ll do tho v.�ork,nnd
�, v:,S'E t.=PaCb'�l -� 1hs struc!uro is nct iNended or offr.ed for�nle,
.- (Sec.7044,8usinesz and Prafezsions Code. 7he Contrcc�
' . . -. . . 'fors Cicensc Law does net apply tn cn owner n7 property
� � . � � - - -� who 6vilds or i^proves thcrron, cnd who docs such
I, � - - work himseff provtded fhal such improvements ore no+
'� � � � � infendedcrol/credlorsale.l`,howevrr,thebvildingor
� . . . . . � � �- . . - Imolovement ls sold wifhin onc ycor of comp!eflon,tF.r
� � - � � tiv+nervbotfderwillhavc ffir,burden of prov;ng tFo�he did
� � /no!bvild or lmprovc for thc purposo af salc I
/ f am exemp!undAr Sec. ,
� � . . . . . � B&P.0 ior this rccson_ _
�
�. -� ,,. , � . . I .
� _� �)LCj�,$
� �Da+e—
Own^r
' INSFECTOR'S NOTES
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