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'�. WORKERS'COMPENSATIONDECLARATION n�sso � appLICATION FOR PLUMBING PERMIT {�
� I hereby atfirm that I have a'certificote af consent to self c�s• ��
��, insure,or a ccrtifiute of Workers'Compensation Insutance,or
� �a tertified copy theraof(Sec.3800,Lab.CJ � ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. ' Compeny
� � CerUfiel copy is hereby furnished. FOR APPUCANT TO FILL IN(PRINT OR TYPEI ADDRESSP�7S OQ� GR� �U
❑ ei2
Certified copy In flled wilh the county buildin`inapection NUMBER FIXTURE OR ITEM • FEE
P 40CAL�TV MOh' �
� de artment. WATEACLOSET �A
�� Uete Applicant NE EST
I BATHTUB cRosssr.f"Ot�ni7A�N S � —r
� CERTIFICATE OF EXEMPTION FROM WORKERS'
, COMPENSATIONINSURANCE SHOWER OWNER ��u�}�M 7, P
LAVATOHY MAII, r !'
(This aectlon nced not be completed if the work involved ADDRESS�G73 CJ�Q(}� C.�GQ�c �,
hy the pemtit is Por one hundred doDara (SI00)or leas.) gINK �-
CITY ���Ojyd �rtQ TEL.NO.��r�'( O
1 certify that in the performance of the work for which Ihis DISHWASHER
permlt is issued,1 shall not employ any pers n ln en manner CONTRACTOR �y (+� Cop.YTJQucT�o%�% �
' so as to eco e subject to the Wark�s' ' �pens n Laws. CLOTHES WASHER O
ADDRE53 � �,(�� j- G�//�� rC� F
i Da[e� pplicen � SWIMMING POOL RECEPTOR V
NOT[ �T AYYL[CANT:If,afte aking this Certiflcete of CITV�OW � �T,S TEL. . �-� �
' Ezemption, you should become subjnct to the Workers' LAWNSPqINKLERSYSTEM STATE LI0. t( �
CnmpenssHon provisions of the Labor Code,You must forth• µ/ATER HEATER UCENSE NO.��S�I�0 CIASS rJ�� �
with comply with suth provisions or this permit shell be
deemed revoked. GAS SYSTEM OUTLETS ��STRICT NO. PROCES Ep BV
' � LICENSED CONTRACTORS DECLARATION OUTLETS OVER O, Q��'��
� I hereby affirm that 1 am licensed under provisions of Chopter 6 PE sYS7EM
� 9 (commencing with Section 7000)of D+vision 3 of the Busi- > ! ��� j/C� DATe yALIDATION
ness and Professions Code,and my license is in fWt force and �«�<I �` T 3—Z—�Z�
I! effect. �
���,��l C FIPI
� Licanse Numb'er� Lic.Cless � gY
�k�d��+, .!=(5l�t no�e � Y 2.
� � I am ezempt from the licensing requirements as I am a Plan eheck fee
licenaed architect or a re;istered professional engineer pLUMBING PERMIT ISSU�NG FEE$
'. acting in my profeasionel capacity (Sec[ion 7051,Hus� ��
Iness and Rofessiona Code). 70TAL FEE .�,� ��
1
� Lic.o�Re'g.No. Date Plen chack appli<ent �
NOME OWNER-BU[LDER DECLARATION
Nema ��� `j Q 2 A '
I hereby aff"vm Ihat ! am azempt trom Ihe Cootractor's Addroat � #• • • • •5
License Law Cor the following reason (Section 703L5,Busi- dty Ts�.No. �� � •� Z�J,�
ness anJ Professions Code): �
; � 7,es owner oC�he property,am exclusively contrecting � •,• •� 2.Jr��
with licensed contrectors to construct the project
� (Section 7044,Bwiness and I'rofessions Code). O�.� 9�a 2
� CONS'IRUCTION LENDING AGENCY �
� I hereby affirm thot there is a construction lending agency
' tor the performance a(the work for which this permi[ ls . �
-' iasued(3ec.3097,Civ.CJ. -
� Lender's Name �
Lender's Address
, I certify that I have read this applicetion and state thet the
above informetton is correct.I aQree to comply with all County SEE REVERSE FOR E%PLANATORY LANGUAGH
ordinances and Stete laws rceulating Plumbing, and hereby
�uthorize repreaentetives of thls ounty to enter upon the �
'. above�mrntioned property for Iry5 ctio purposes. -
w \ r �
�� SignatureoFYer it e Dete
AF'PROVALS � �DATG 11,^,7ECiORSSIG":ATUREg � � irasaecroF�s rv'OTES' _� 01���ER-IIUILDER DLCLAR1�TIOi` ,,
UN�EFi SLAB WORK � � . �- �
RO'JGH PL,UM�IING � � 1 hereby affirm tii�t 1 am esempt from the Contracmr's
License I.au� Por tlic follow�ing rcason(Section 7031.5.
GAS aiPwc - � � ��� � • -�� � -- � �� � � ' Busir.ess and /7ofessions CodeJ: Any ciip or counry '
3q5 veHT '. . . . - xJ�idi requires a Pennit to mnstnfct, n7ter, impro��e,
H07 vJAreft H[ATen � � - demoJesh,or repQir an}�sbuc��ve,prior to its issuor�ce,
, , � , also requirer 11ic opplrcant jor sudr perrttit lo frle v
r��un�awc FixTv9es,- - �- — - si«�+ed rta!rmeru that he is !(teirsed pursrem�f �0 1Le
GaS TeS7� � � �- •� • � prorisionr of dre Contractor's Lrcense Law JCimpter 9
uTiLi7v co.NOTiFI�� � (commencing witlr Secti�in 7000) of Dirision 3 of the
.. _ _ .. . . . . . 17rairecss m:d Profcssions CodeJ or that he is esentpt
� ' � 1lrerefran:m�d,rke Gasit for the olleged exerr.ption.Anp
FINq� ��L'tti�eii'Urr. �3o+st �� � � � � � , �'iolcrion of Seclion 7031.5 bymt}•applirmrt fora penni�
, , � � ,, , , . svb%ects d�e epplicaru to a cieil per�a[ty oJ rtot�nore rlian
itvousTR�A�� . � , _ �-.� � � � ; -jirehurtdreddo!lars($5001.:
wn57[�.raFOvn��- � � �� ❑�1.as owncr of thc property w�ill do Ihr work,and
tltc steucture is not in[endcd or ofCeced for sale.
' � � ' � • _ . - • � ,..,(Sec.'705�1;E:arncss m�d'F'rojessions Cnde; The Cv�r-
� . � ., � � , . ' . • trac�oi's %icense Law does trot apply !o'an owner uf
' ` ' � � - -_ �.- . ' �� - prnpen}'.w&o 6uildr or improves rhereat,and�vho does
� . � . .. . .. . .s�tcl� x�ork hirruelf prm�ided tliu7 suci� impro��eniertts
� - - - � � � � �� � � - ore not inte�tded or oflered for sele. If, however, thc
'. . . .. . . . . ,, � Luildin„^ ur in:prm�cmeiu u sold within orre }�ear of �
. . � cernP(elion. Ihe ownerbuilde� wi!! Aave tGe burden
' ' . .- _-!. - ' � � , of proving rhat fte drd r�ar build or improre Jor 8ie
. .. .., . � � � ' purpose of salc.) . .
- �_ � I am exempt under Sec. ,
— "13&P.C.for ttiis reasou `' ,
_ Da[c
_ Owncr
� �� INSPECTOR'S NOTES '
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