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Home My WebLink About1778A i WORKERS'COMffNSATION DECLARATION APPLICATION FOR PLUMBING PERMIT � �t I hereby affirm thaf I have a cerlificote of conseN to seH �dqyb�q � insure,or o certifico�e of Workars'Compensalion Insuronce, CE 8�7(REV.IOi81) ( o�a cerr'rf� copa.rher Ssc,_a,tlb�C.)� � COUNTY OP LOS ANGELES BUIIDING AND SAfETY � ❑cYN `6 Company `�T�f7�-� �'1"� Certified copy is he�a6y fumished. i f-0R AVPLICANT TO fILL IN�PRINT OR TYPE) BUIIDI ' I � Cer�ified copy is filsd with the coun�y building inspeo- ADORE55 Z� �t�� fion de rt eni. NUMBER FIXTUREORI7EM FC fEE LOCAUTY f Da1e l r �m APP�'Ganl - �,C.� WA7ER CLOSET NEARESi / �, �� j� �y�,�/ � CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB � CROSS ST. lr.(!/j'r 1�✓L 4 L�i1'L�� '� COMPENSATION INSURANCE SHOWER OWNER �j i (Thi�s�ctian n��d not b�complN�d if th�work inreW�d by � � th�p�rmM i�fe�an�hundr�d dollan(SI00)or hn.) iavatoRv D�ESS ��Cf l �� 1 I cerlify thol in the performance of the work for which this � permil is iuued,I sho71 nof employ any person In ony monner SINK - CITY � r ��i e O TEL.NO.� - yv` �, s0 as lo beCome subjec��o!he Workers Compenfofion Laws. pI5HWA5HER � � CONTRAROR � l' 1 , Dv�e 6Tpli[oM CLOTHES WASHER � �/ ` , .�1 �J/ ADDRESS ; NOTICE TO APPLICANT: I(, aNer moking this Certificale of l`( ��t� JL Exampfion, you should bemmw su6ject �o �he Workers' SWIMMiNGPOp�RECEPTOR _ ` Compensotion provisions of Iha labor Code,you musl fonh- ��T� 'l�C �yt_ TEL.NO. �� , wifh comply wilh wCh provisiom or ihis permif shall be �AWNSPRINKLERSYSTEM [� 7�G'' � deemed�evoked. . WATER HEATER LICENSE NO. �i�/[/,,J� C ASS � , IICEN5E0 CONTRACTORS DECLARATION DISTRICT NO. ESSED BY 1 he�e affirm�hot I om licenaed onder GAS SYSiEM OUTLETS by provisions of Chapter 9 (commencing wirh Section 7000)of Divicia+3 of�he Business outtEiSOVER and Rofeuions Code,and my I�cense is in full fmce ond effec�. s vER 5vst[m FINAI VALI TION . licanse Number-I�/�`�'� lic.Class�� ATE ��R� T O ConhaU6r—��"+ "Y�`�x�"e� . BY AL U. I ❑ LL' I am exempt under Sec 0 U 8.&P.C.for ihis reason W Plon check fee p�. ��e� GLUMBING PERMIT ISSUING FEE E � "�� 7 7��A Z , Signolure � TOTAL FEE {�• • • • •Jr � ' � Plan check oPPl�cant - � • • � 6 5� SINGLE FAMRY . HOME OWNER-BUILDER DECLARATION Name , • • • � Q Jr O� I hareby offirm lhot I om exempt from the CoMroctor's license Address D 1.0 8—8 7 , low for ihe(ollowing reoson(Seciion 7031.5, Business a�d � . Profess�ons Code): City 7e1.Na. ' ❑ I,os owner o/the property,wfll do the work ond the � stroUure is nat iNanded or offered fof su�e (Sectian , � 70��,Business and Professions Code). � � :ONSTRUCTION LENDING AGENCY . I hereby affirm�hot there is o construction lendin9 agency!or " � the performonce of fhe wark for which this permit is issued � (Set.3097,Civ.C.). , Lender's Name � ' Lender's Address ' I certify thal I have reod Ihis application and state Iho�Ihe � � above informolion is correcl,I ogree b comply wi�h oll Counry ordinonres and Stote laws ragulaiing Piumbing,and here6y aWhorize rapro�entatives of this CouNy io enler upon ihe ', above•mentioned p.operty for inspecron purposes. SEE REV6RSE FOR EXPLANATORY LANGUAGE /Y��---� � �`7`�7 ' �Signature of Perminee Do�e - I. AP7ROVALS onre � iNsa[eToa�sSiGNntuae INSPECTOR'SNOTES O`NNER-BU4D'cRDFCI.ARAiION � UNDER SLAB WORK I herchy oFfirm Ihat 1 am ezempt Gom the Conrrnctor'a ROUGHOIUMeING Lic�nse Law for Ihe followirg reason (Sec!ion ;03I.5. GAS F�PING � ' ' � -� �uslness ond Pro(easions Code1:Any cify or roy��y wf:�ch � GAS VEN7 requlres a perml�to construc�,alter,Improve,demolis.4. . or repair any structure. prior to Its issuance, olso re� HOT WATER HEA7ER � . . quiros fhe opplicont for soch permlt!o file a signod sec!e� � vtUM6iNG�izTU+FS � � ment thaf he is ficensed pursuant lo Ihe provisicns of the , GAS TEST Cortfrc[to�'s Ltcense Low(Chopler 9(rommencing.•�i'h � U71U7YC0.NOTIFlED ' Section 7000)of�Ivision d.ol fhe Bus�ncss,ond Profes� i . stons CodeJ ar that he is exemp�therelrom and�he bosis f � /or fhe alfeged e mption. Any vlolallon oi Sccllon '� F��A� `�e1cr on �rnrs( 703L5 by ony opplicon�for o permil subjects fh_appli� I cant fo a civil penally ol nof more than live hondred I . dolfors(5500).: INDUSiRIAL , � _ ❑I,as owner of the property will do the work,ond ` vaASTE AFPBOVn�� the structure is not intended or offered for sole. � � - (Sec.70�f,6uslness andPro/csslons Code: 7ho Confroo ' � � � � � . for's Gcense Law doas not apply to on owner ol property �' . . � ��who bu7lds or(mproves fbereon, and who dces such � � ' ' work himself provided lhof such lmprovements are nof � � _ - lnfanded or offered for sale.!f,however,fhe 6uliding or �� . . , , . . _ lmprovemenf Is sold wffhin one year o/comple�ivn,th.e . " " " - ' � owner-6uffderwlUhavetheburdenoFprovingfhofhedid � not butfd or Improve!or fhe parpose o�salo.) 1 am exemp`.under Sec. , -, _ ci; , . - - . . ' B 8 P.C.for this reason � . � . � � ' � � Date � .. . Owner INSPECTOR'S NOTES