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>✓ ��WORKERS'COMPENSATIONDECLARATION �•�••�� . , APPLICATION FOR PLUMBING PERMIT
' I hereby affirm that I heve a'certificata of consent to self ct�v�z-so �
� insure,or a certificate of Workerc'Compenss[ion Insurance,or -
'� a certified copy thereof(Sec.3800,Lab.C.)
COUNTV OF LOS ANGEIES BUILDING AND SAFETY
Policy No. Compeny - � - � � - -
I � CertiCied copy is hereby Curnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE1 OUILDING . y� ���isp�,,o /
AOOHESS ��^�����'��
� � Certified copy is filed with the county 6uilding inspet[ion NUMBER FIXTURE OR ITEM � FEE �'� o�n
�iepertment. / WATER CLOSET �� LOCALITY 6 ��
' Dote Applicant NEARE57
� BATH TUB CROSS ST. O�I.iS�\ _ � �
�� CERTIrICA7E OF EXEMPTION FROM WOKKERS' q� -
� COMPENSATION INSLIRANCE � SHOWER � OWNER ,�7ra--x �(/�(/�
� LAVATORV _ OO MAIL � . Y�
.. (This section need not be completed if the work invotved nDDFlESS J��7 G �F���� �
� by the permiY is for one hundred dotlars (S10D) or IeesJ SINK
Q CITV �� 8M( TEL.NO.�4y�+f�y�? C)
� I certify that in the performance of the work for which thfs / �ISHWASHEF � d CONTRACTOR��/,/L�•' Uy�j7;�y ' O
�. permit is issued,I shell not emyioy any perwn in any manner �
: so as to e me subject to the/Wo�ry�/' ComDens on Law�s. CLOTHES WASHER ADDRESSsr�� ��/� �p �f� U
Da[e s� App{icant �v�y�� SWIMMING POOL RECEPTOR ' 4-
CITY !N TEL.NO���-ti'G� tA
�� NOTICE TO ANYLICANT:If,aftar makiog this Certifcate of �� '' Z
Exemptian, you should become subject to the Workers' LAWN 3PfiINKLER SYSTEM STATE �1 LIC. —
� Compensation provisio�s of tha Labor Code,you must forth- WATER HEATER LICENSE NO.Z�?��7 CLASS 6�
with comply with sueh provisions or this permit shali be DISTRICT NO. P CESSED BY
j deemedrevoked. � GASSYSTEM OVTLETS /�
i LICENSED CONTRACTORS DECLARATION OUTLETS OV ER I lJ �'
� I hereby aftirm ihat 1 am licensed under Drovisions ot Chepter 5 PEP SYSTEM
� 9 (commencing with Snction 7000)of Division 3 of the Ausi- DATE _Z yALIDATION �
i ness and Professions Code,and my license Is in full lorce and �- `�'��
� eflfcct.
i � FINAL � ��
� License Number�;��f9 y LiC.Class 6 BY �.
; Contractr���`"'"'�Date �f`7��
'� � Plan check fee
1 am exempt trom tne licensing requirements as I am a
, �- licensed architect or n registered pcofesaionel engineet pLUM81NG PERMIT ISSUING FEE$ - � - �
acting in my p�ofexsional capacity(Section 7051,8us• `
, ` iness and Professions Code). � TOTA�FEE �j �
��, Li,or Reg,No. Date Plan theck epplic�nt
�HOME OW'NER-BUILDER DECLARATION Nama G ✓4/I �
' I hereby affirm that 1 om exempt from the Contractor's Aad�°49 3y��'E '`�>'''� �
' License Law for the(ollowing reasoa (Section.7031.5,Buxi- C�iy�,op���,f� Tel.No. �OG� � ' - � �
l ness and Professiuns Cude): �� /8.9 A
� � I,as owner of the property,am exclusively contracting � �
r with licensed contrac[ors to Construct the project _ $�� ��� � �5
(Section 7044,BUainess and Yrofessions Code).
� I • •2&50
CONSTRUCTION LL•NDING ACENCY
I I hereby aCfirm that there Is e construction lending agency ��` '��J�c=.o
for the performance of the work Cor which this permit Is
issued(Stc.3091,Civ.C.), � ���4�'8,�
Lender's Name . , .
LendePs Address .
� I cerHfy that I have read this apP��cation and state that the
n6ove information is correct.1 apree to compty with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
� ordinances and State laws reguleting Ylumbing, and hereby ,
.authorize repreaenfatives oF this County to enter u{�on thc
����above•ment' D P�t mspection purposes. �
`�t ��'��.�� i �/
'�,� Signa�ure o Pt�mi[tee ete � � �
i'
_
APPROVALS DATE INSPECTORSSIGNATUq[ ' INSPECTUR'SNOTES' � ' � - '� -01'iNLL:-B�i�ILUF'.P.DLCL,�.RATIO:\
UNDERSLABWORK � � �� . � �
ROUGH PLUMBING 2 2���,_. I 1:emU}�affirm thst 1 am e�empt Irnm t6c Contractur's
— - Cicensc Lao� (or thc follo«�ing rcason(Scr�inn 703I.5.
GnS aiPwG .. .. .. . . .. . .. . . . . .. - � _ Ricsi��css mrd Projcsr.'or;c Co�!�y: An}� cr.�i� or ro�r.r7��
GAS V[NT � � '�� • _ � . . . . . � . ��'ltidt reqi:ires e pennit to conrrruct. a!ter, inaprore,
HOT WA7ER HEATER . � der;m(iJ�,or repa��m.Y stn+clurr,prio.��o its isv+mrce,
PLUMOING FIXTURES �� � � � L'150 I'Ctrl:l.'f.T lJlc a�^()licGrtf f[ir SUtl� (lerlttit f0 fl:c 4
si;;r.ed sta�emerrt d�et he is licenred pw.cur.rn to rhe
' GASTEST • ' , (ro�'isiwtc of t!re Conrracmr's Licrnsr I.nn�/Cimpt�'r 9
UTILITY CO.NOTIFIED , _ �CO»tn;�•�;;�r;,�• ��'ifJl $eCti:>l! 7OOOJ Of Dirision ,3 OJ tlre
,aL�� . _ Gusr�rcrs und Po�o(<'tsioru�CoAey or d�at hc is erenrrr7
FINAL . . . . , th,c��rfrmr:¢r,d flic ba;is fur 7Le uRcl;rd rxempliort.An}�
�'�t.tpJt Wi ��t6+i� � � riolation of Scrtioir 7031.5 br mt}'ePPlica'rr7 jor a pennit
_ s�+hl�'cts 17ic c�ppficcut to a eiri!pe�ialtl'oI��o�rnnrr t7tarr
� iNOUSTRinL � -, - � . - � . fivchundrerldot'a�s(55�OJ.:
'.NASTE APPROVAL ' � � - ❑I.2ti U�cnc�of[hC p[opc[ty uill dU the acork,and
�the siructuec is not in�cr.dcd or o(frmd faz salc.
� ' - �-� - • � �_ ;Srr. 70-i1, P•r'ti;rres.m+d Frnfcssinrs Codt: 'Tl�c Cort�
, . � . . . . tructor's I.iccr.sr Lc�r doCa rmt app!}� to�an oirircr nf
� .. . , . . . pro;��rtl'+�•J:o Luild.c or improres tlirrrwr.enr!xdm does
. . . . . . sncl: icor.( kin'sclf prorided �l:at sucf; im;�rorente�rts
.. . .- . .� ... _. . . . � ure rto: iiuendeA or offcr.d jar ta1P. Ij. hn�.�erer, thc
� � � � � - - buildir; w ir�rprorcnrcrrt is rolJ itrthir. mie rcar oJ
, . � � , � rompleliwi, tlrc n�wterLai(d✓ xi7! l�are !hc b.irdeu
_ � .. � � . . . � _ � . . .� .. ��f��rori�i,, rf;et !re di;f not b«ild or imprnre for tGc
�. � purp.�reof.cate.J � �
_ . 1 am e�empt under Sec. ,
B�P.C.for this rca.nn '
Datc
— O�cner
INSPECTOR'S NOTES � * . . � . - . � �
�