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Home My WebLink About1777A � .. _ . _ ��.. . '� WORKERS'COMPENSATION�ECLARATION APPUCATION FOR PLUMBING PERMIT � . I herehy offirm rha� I have a certifitate of consem fo self �yq�y�q li,� in3ure,or a certifim�e of Workers'Compensafioo I�swance, CE BU(REV.10i91) . or a cer�;e�d co��r�q {�es.�,56.�G.) I ^ � � COUNTY OF LOS ANGELES BUILDING AND SAFETY ��G � acynf6�� Company �� Ce�tified copy is hereby furnished. BUiID�NG�(��' /-.�� 1 ^ FOR AP7UCANT TO fllL M(PRINT OR TYPE) ADORESS W�� ! J L' � I/1 Cerlificd copy is filed wilh Ihe caunly b�ilding inspec- � �`--� lio��ricrA,�ey�, NUMBER FI%TUREORITEM (� Fff � � U� C/'�--� WATER CLOSFT LOCAtITV � �� '� Datg � AppliS � NEAREST ^-�M � CERTIFICATE OF E7(EMVTION FROM WORKER' BATH TUB CRO55 ST. L,�E'l�I� � �/�Y,/� I COMPENSATION INSURANCE OWNER � j (Thls pellon ne�d not 6�compt�t�d U fh��rork rolvrd by SHOWER �+-��y/ I fh�permiT i�lor an�hundnd dollan(S10D)or bss.) LAVATORY ��l '1 ( {� �G � �r ADDRES.i � I cartify thol in Ihe perFormdnce of Ihe work for which this � pe�mit is issued,I sholl not employ any parson in ony manncr SINK CI7Y t,rV�� TEI.NO. .f��f so as fo become wbjac7 l0 1he Workers Compenwtion Laws. /�' � �4 � DISHWASHER CONTRACipRC�Gt�� L�L I � Dale ApplicaN CLOTHESWASHER ADORE55 'Lf/� .y� � NOTICE TO APPLICANT: If, ofler moking this Cerrificale o( SwiMhuNGVOOLRECEPTON 'ii Easmp�ioo, you zhwld become subject to fhe Workeri� U7Y ' TEI.NO. - ,I Compenso��on provisions oF the Lobor Code,you musl forlh- WNSPRINKtERSYSTEM `� �� .� with comply with such provisions or this permi� shall be STAIE �(, � LIC. /� deemed revoked. WATER HEATER UCENSE NO. � ClASS L• I LIC@NSED CONTRACTORS DECLARATION DiSTRICT NO. ROCESSE BY GAS SYS7EM OU7lET5 �J � � I hereby affi.m thar I am lice�sed under provisions of Chap�er 9 �� ) (wmmeacioy with Seclion 7000)of Division 3 01 the Business OU7lEi50VER �� and Professions Code,ond my litense is in full force and effecl. 5 PER SYSTEM FINAL /J'7 DATE /�I�� VALI ION � .r Licensa Numbar T ✓��`�� Lic.Class�� ` j ��. �j� 1 �--777 FINAL U I� Coniroctbr��`��"'7v�� BY � � ❑ I am e.empi under Sec. � U B.BP.C.for this reason W Plan check fee ► d� ` Dore: PLUMBING PERMIT ISSUING FEE S Z � $ignature � TOTAt FEE ;_� 7�.']A � Plan check applim�t ti• . . . •rJ SINGLE FAMILY . HOME OWNER-BUILDER DECLARATION Name I e • � Ci J�O � I hereby affirm fhat I om exempt from the Conhactor's License Address Low for Ihe followin9 reason (Secfion 7031.5,Business and • • � 1 6.5 G u _ Professio�s Code): ��y Tel.No. ' ❑ I,os owner of 1he properiy,will do the work o�d the ��.�fi'8 7 C structu.e is not imended or ofiered for wle(Sett�on � 70a4,Business and Professions Code): � � � CONSTRUCTION IENDING AGENCY � I heroby aHirm tha�there is a mnstruction lending agency for the perfwmance of the work for which ihis permit is issued (Sec.3097,Civ.C.). . . Lender's Name Lender's Address ' I cerfify tho�I have reod this npplication and sfa�e that the . � obove informotion is corcec�.I ogree Io comply with oll Counfy - � ' ordinonces ond Stare lows reguloting Plumbing,ond hereby ' ouihorize repre�eMativas of this Counly fo enter upon fhe , . above�menrioned property for inspec�ion purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE ; �, _ �_ � � _�� i§no�ure o�Permittee' � Date - � qvpRpvc.t5 DATE WSPECTOR'SSiGNATURE MSPECTOR'SNOTES O�'/NER-BU�LDERD=CI.ARAiION UNDER SlA6 WORK I here6y offirm Ihat I am exempt(rom the Conirec!o�', ROUGH PIUId.BING - � � l�Cense Law fo� fho following renson (Setfion J031.5. ' GAS FIPING. � ' � �� Buslness and Prolessions Code7.Any dty or county wh�:h GAS VENT • requires o permlt to ronslrucf.aher.improve.dsmoLs6. o�repait any slrucfvre, prior fo ifs hsuancc, also re- HOT WATER HEATER � ' . . � quiree fhe opplimN(o�such permif fo life a ti�ned s�neo- '�. �lU'.�B�NG GI%7URFS meM fhaf he Is licensed purtuan.•to the provisionz of�he G/+STEST ' , Con}ractor's Llcense Law(Chapler 9(mmmenUny a�ifh UTiUTV CO.NO7iFlED � Secffon 7000J of D(vlsion 3 of the Bus(ness and Prafei� � slons Cade)or thof hc is exempt fherelrom ond the bosis i c7 ' for ihe olleged excnp�lon Any violaHon oi Setlion FINnL � � �(��/�r on Jronl � . 7031.5 by vny applicanf for o permif svbjecfs fhe appli- I - cont to a ciWl penaRy of not more fhon five hundred � � dollon(5500).: � � WDUSTRIAL ' , , ❑i,as owner of the properry aiill do thc work,ond NJAS7E AFPBOVAL ' tha strutfure is nol intended or offered for sale. ' . (Sec_70«,Business pndProless�ons Code: iheCon�rac- � ,. . ' tor's Cicense Law doas no�apply to an owner of property ',� , � , . � wbo bvflds or Improves thereon, ond w6o docs such , work Blmsel/provlded Ihat such lmprovements are nof � � . Intendedoro(fered/orsale.lf,howevcr,��hebulldingoi � _ _ , . , - Improvemenf Iz sold w(Ihln ona year o1 complo�ion,fhe - - � owner-bulfderwlll have fhe burden of proving thof be did � not bofld or tmprove for ihe purpose o/sale,) . -:�• t am exemp!under Sec. _�,ti� , ' � B&P.C.for ihis reason . - . �- . � Dore � Owner INSPECTOR'S NOTES I