HomeMy WebLinkAbout1776A WORKERS'COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT � ��
I hereby offirm tfioi I hove o ceni(fca�e of consent to self �b,qyy�q
insure,o�a certi(icote of Wo�ke�s'Compsnsation Inawonce, CE 817(REV.10/81) . .
� or a cerfified co y h 4 c lob. .)
2���d�'Pj�`. COUNTY OF LOS ANGELES BUILDING AND SAfETY
P�olicy No. Company
CerfiFied copy is hers6y f�rnfshad. a�'—
FpR APPLICANT TO FILL IN(PRINT OQ TYPE) A�����Q V e�+"�--- 1 I�,
Carlified copy is filed wilh 1he counfy building inspeo NUMBER FIMURE OR ITEM @D FEE
. tian de iment � �� ����Ty n�
Da�e � ���Appli4ont � WATERCLOSET NE�4E5T / �y�,�
� CERTIFICATE OF EXEMGTION FROM WORKERS' &4TH TU8 CRO55 S7. (i¢2���• �-�--' !�Q—
COMPENSATION INSURANCE SHOWER OWNER . �'� CJ +
(Thla�Mion n�ed not b�rnmpl�Nd if tho work imolwd 6y
th�p�rmN b lor one hvndnd dollan(f100)o.I�u.l LAVATORY ��� �Gj C/ �
ADDRESS
'� I certify ihat in the performaoce of ihe work fo�which this
� � permif is iuued,1 sholl nol emp�oy ony person in ony manner SINK CRV �v��� , 7EL.NO.���
to as 10 become subjecl lo the Worker%Compenaotion Laws. DISHWASHER
CONTRACTO����� � 1 ��
. Da�e- Appiico�� CIOTHES WASHER qpp(�55 I y���"a .0
� NOTICE TO APPLICANT; If, aher mokinq thia Cm�ifimte of '
Exemp�ion, you shoold become sobject to the Workari SWiMMiNGPOOLRECEMOR
. Compe�so�ian provisions a{the Labor Code,you mual fo�1h- �qWN SPRINKtER SVSTEM GTY �J j�_ TE1.NO. (
wi�h comply with such provisions or Ihis permi� sholl 6e S7ATE .C�. `�y3� LIC �
' deEmed fevoked. WATER HEATER UCENSE NO. C1A55
LICENSED CONTRACTORS�ECLARATION. �ISTR�ci NO. ESSED BY
, I hereby offi�m thor I am licenaed�odar provisions of CFwpter 9 GAS SYSTEM �OUTlETS
(tommentinq with Section 7000)of Divia�on 3 of�he Buainess OUiiEi50vER
ond Pro4essiorro Code,and my I�ceme is in full force nd effect. 5 aEa 5v5iEM FINAI
�'�j VALIDA ON �
' License N�utmber' n���`�J Lia Clou �� DATE � ��
' Contmc�j`I' ` 'r �e�� FINAL U
8Y
a
I ❑ I am ezempt under Sec. �
B.BP.C.for thiz reason ► W
Plan check fee �1 7 7,6 A �
, oa�e:
, PLUMBING PERMIT 155UING FEE S , �+ • • . • •� Z
Signofure '
' TOTAL FEE I • � � � 'rJ O
. . - Plan check applitant • • • � �'5 Q=
S�NGIE FAMILY
HOME OWNER-BUILDER DECLARATION Name O�,O�.—B�I
I hereby offirm that I am exampi from tfie Contracfor's liceme Addrass �
� Low for the following reoson(Sedion 7031.5,Bosiness ond
Professions Code): Ciiy 7e1.No.
❑ I,os owner of ihe propeny,will do the work and the
structvre is not intended or offered for w�e(Seclion ,
7044,Business and Professions Code). �
� � CONSTRUCTION LENDING AGENCY
, 1 here6y nffirm tho�there is a constructian lending agency ior
, the performonce of Ihe work fo�which this pefmir is Issued
, (Sec.3097,Civ.C.).
Lender's Name
Lender's Address
. I certify thal I have reod Ihis applicolion and sta�e 7hat the ► �
above informa�ion is carrecL I agree to comply with ali Counly ' � � -
ord�nonces and Stofe laws regulaiing Plumbing,ond hereby
authorize repre�entativas of this County ro enter upan Ihe
obOv -mantio�ad prope��y for InspeU�on purposes. .
���A ���___�-j---� SEE REVERSE FOR EXPLANATORY LANGUAGE
� J [
S�gnaiure o£Permuree Da�e
AC7ROVAlS onre INSPECTOR'SSIGNATURE INSPECTOR'SNO7e5 OYVNEP,-BURDeRD:CI_4RAilON
UNDERSlA6YJORK I here6y effirm tha�I am rxempt(rom�hc Convr.ao•'a
ROUGH PLUh181NG License L�w far tho followirg reason (Seclinn 7031.5.
GAS CIPIVG� - " ' - � Business ar.d Prolessians Coda?.Any cify or ccunfy wF�ch
GAS VENT � � � requires a permlf to construcf,alter,Improve,demofis.h.
or repair any siructure, prior�o!fs issuance, olso ro-
HOT WATER HEATER - . - quires the oppficonf lor such permft lo/ife a signed sfr.le�
v:U!.+6it�G FlxtUaES � ' menl th�t he is lirnnsed pursuont fo Ihe provisions of rhe
GASTEST � . . , Confractor's Lkense Low(Chep�er 9 f�ommencing��,ith
U7iUTY CO.NOTiFIED Sectton 7000j ot pfvision J of Ihe 8usrness ond Proles-
sions Cade)or that h^�s exempf Iherelrom cnd ffic bvsis
f c7 � - - !or the alfeged excmpHon Any viafafion oi Sertion
F��A� ' Gnl¢r an �irorzl � � � , 7031.5 by any applicon�for o permi�subjects fhe oppli-
� cant�o a civil psnolty of not more fhon(ive hundred
' � . . dollars(5500).:
WDUSTRiAL ❑I,os owner o`ihe proparty will do�he work,ond
w.�57E aa7Rova� � tha strocture is not iNended or offered for sale.
(Set.�70M,Huslness and Pro(essions Code: 7he Conlroc-
� ' , , . tor's License Law does not apply ro an owner o�proper�y
� � � � - � who bvi(ds or Improves fhereon, ond who does such
� � work hfmsef{provlded IFa�such fmprovemenfs ore noi
, � � _ - � � 7nlendsd orollered io�sole.If,Fowever,the bvJlding o�
, lmprovemenl ls sold wUhfn one yeor ol complerion,�he
� " � ' � - owner•bu7lderwlll have fhe b�rden ol proving Ihaf he did
. ' ' � not,6uifd or Improve(or f6e p�rpose ol sale.) .
, . �. _ . . . , .
- f am exempt under Sec. ,
.:�ti: . ,
� ' � �� B E P.C.for this reason I
' ` ' ' ` � ' � Datc
� ' � Owner
INSPECTOR'S NOTES
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