HomeMy WebLinkAbout1775A WORKERS'COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT �
I hereby affirm that I have a[enifimte of conseM lo self 76A667A � '
insure,or o certificate of Workeri Compensotion Insuronce, CE 817(REV.10/81) . . �,
or a certified c 3800.Lab.C 1
����j. _"L S��� _ COUNTY OF LOS ANGELES BUILDING AND SAPEIY
Policy�o� Company
- � CeAified copy is here6y fumished.
FORAPPLIUNTTOFItIIN�PRINTORTYPE) bUILDING://7�C"j)� j.f ��
Ceriified mpy is filed wi�h ihe county building inspeo- rtDDRESS !Jy�.J V/
, ��✓��� � � NUMBER fIXTUREORITEM F� FEE
�' WATER CLOSET ��+��TY J
� �ote Appl;tun NEARESi
� CERTIFICATE OF E%EMPT�ON FROM WORKERS' BATN TUa CRO55 ST. � � �Y�� I I���
�. COMPENSATION INSVRANCE SHOWER OW��ER � „ �7
�� (TAfs t�etion ne�d net b�campbted k fh�work tnroiv�d by MAIL l''7 r'^
Ihe p�tmit is ior on�hundnd dollan(f100E or I�aa.) LAVATORY ADDRE55 l. C��� �/V' �
I ceriify tha�in the periormonce of ihe wwk for wh�ch ihis
permil is iu�ed,1 shell nof employ any person in ony monner SINK ' CIN �"(����_ TEt.NO.
� so oa to be<ome subjacl fo 1he Wo�kers'Compensotion Lows. DISHWASMER ��i!
CONTRACTOR V.—�
' Dofe Applitant CIOTHES WASHER A�ORE55 , 1�� ' (i(� L L
� NOTICE TO APPLICANT: li, afler moking Ihis Cartifimte of SWIMMINGPOOIRECEPTOR
Exampnon, you should become subjeu to rhe Workers' � ��
Compe�sarion provis+ons of�he lobor Code,you must fonh• Ciiv ,� �ry�, iEl.NO.
�AWNSPRINNIERSYSTEM �� J�� �
� wiih comply wi�h s�ch provisions or this permit sholl be Sinie 7 uC.
deamed rovOkeCl. WATER HEATEk LICENSE NO. CLA55
LICENSED CONTRACTOR$DECIARATION DiSTRiCT NO. ESSEb BY
I hereby affirm Ihal I om licenaed under provisions of Chopler 9 GASSYSTEM �OUTlE75
(commencing with Seclion 7000)of bivieion 3 of�he Business OUTlET50VEk
� and Rofessions Codb,a��y�cense is in full force ond effect. 5 aea SvSiEne FINAI VA�I (�N
. �� J� /'�,� DATE � ,q��' a�
License Nomber Lic CIos3-� p
, ��� _�.,`� /��� FINAL U,
Comra ��`< < BY
❑ Z �
I 1 om exampt�ndet$ec. • �
U
' B.BP.C.for this reoson �� 7 7,5�` W
Plan check fee � 0.�
�
� Date: plUM81NG PERMIT ISSUING FEE E � � � � � �5 Z
Signqture TOTAL FEE � • • � �i 5� �
-� �� Plan chetk appliconl ♦ • • � �5 p= .
' SINGLE fAMILY ' �
HOME OWNER-BUIIDER DECLARATION Nome . O��O F7—�rI
I hareby affirm iha�I om axampt from the Coniraclor's licensa Address •
Law for fha following reason($ec�ion 7031.5,8usiness and �
Professiona Code): City Tel.No.
❑ I,as owner of the property,will do Ihe work and Ihe - '
' structure iz not infended or offered fof sale (Section �
7044,Business ond Profassions Code).
CONSTRUCTION LENDING AGENCY
1 hereby nitirm Ihot there is o construclion lending agenq for
iha perfwmoace oF the wark for which lhis permit is issuad
(Sx.3097,Civ.C.). - � � .
lender's Name '
Lender's Address - '
I cenify ihat I have read th�s opplicof�on and s�a�e rhat ihe �
obove informotion is correcL I agree lo comply with ull Coonty ' ' - '
ord�nantes ond Sto�e lows regulaiing Plumbinq,ond hereby
auihorize repre3eniauves of this County�o enter upon the - ,
a6ove-meni�oned property for insped�on purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
`/�,��' � .s �'7"``�
Signoture of Permitle �ote
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. ncp�ovnts DATE INSPECTOR'SSIGNATURE. �NSPECTOR�SNOTES O4VNER-6UILDER n;G.�RAiiON �'
i
UNDER 5[Ae WORK I heroby oFfirm Ihat I am ezemp�from the Conirocror';
ROUGH PNh101NG Liconsa Lav� for tha followinc� reason (Seclion 70J7.5. ,�
GAS PI?ING ' � - Business and Prafassians Code):Any cify or counly w4+th ,�
GFS VENT _ requires a permil fo conslrucL olfer,improve,d=mobsh,
HOT WATER HEATER or ropair ony structure,prior fo ifs iszuance, also re- ��
' quires fhe appliconf lor such permil fo/ilo o signed sfate- ��
PLUMBING FlXTL'RFS - . ment fhat he Is licensadpursuant lo tl�e provisions of 1he
� Gn51E5T � Conlrocfor's LJcense Law(Chapier 9(commenUng.•.irh "�
UTILI7YC0.hOiIFIED S�c�ion 7000)of Division 3 of fhe Business and Proles- ��
. � sions Code)or that he is exempf fherefrom ond the basi:
r � fo� fhe alleged excnplfon Any vio�alion oi Secfion �
F��A� � � !n(cr w. �iml � � � 7037.5 by ony oppliconf lor o permit subjects Ibc oppli� ��
. . _ - tanf to a tiviJ panolty of not mora Ihan(ivo bundred
. . doltars(SS00).: ��
INDUS7RIAL . - � . . ❑I,as owner cf fhe property will do tho work,ond ^
w:.STE ticpdOvn� � the sfructuro is noi intended or offered ior sale. ��
(Sec.7W4,BuslnessartdProfessionsCode: 7heCon�rac- �i
'� � ' - � . �fo�b Lleense Low does ttot opp7y!o an owrrer of prpparfy {
, - , � � � who builda or improves fhereon, ond wfio does such �
� � work himseff proridad 1ho�svch improvements ore na/� i
, ' , !nlended or oHered fer sale.lf,how¢ver,the 6uilding o� �
. . , , . Improvemenf Is so7d w(fhin one year ol complation.1ho �
, owner-lwi/darwi7lhovefheburdenolprovingtho�hed;d -�
. � - nof build or Improva(or the purposa o/sole.)
,. - I am examp!under Sec. +
' � B 8 P.C.for this reason I
. = . . �
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Date
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- Owner
INSPECTOR'S NOTES d
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