HomeMy WebLinkAbout1704A (17) woRKERs'�°^^°ENS^T�°N°E«ARAT�°N APPLICATION FOR PLUMBING PERMIT {� ;
1 hereby offirm Ihal I have a certificate of consent to Self 7gqy�7q ��
`insore,or o certificatt of Workers'Compensation Insurance, CE 817(REV.IOi81� ,
or o ce�nf�ed co y ih eof(Sec.3800, b.C.) COUNTY OF LOS ANGELES gU1lDING AND SAFETY 7
Policy No. Campany � � , /
� Certified copy is hereby furnished. BWI�iNG 1 . �"�
OFOR APPLICANT TO FILL IN(PRINT OR TVPE) A�DRE55 )
Certified copy is iiled wiih the�county buildi� inspec-
fion epor enl. - NUMBER . FI%TUt7E OR ITEM Q FEE ��ALITY
WATER CLOSET
Dare Appticonf • NEAREST
ERTIFICATE OF EXEMPifON FROM W ERS' enTH rue CROSS ST. -
COMPENSATION INSURANCE OWNER QvL
SHOWER
(Thit��efion nNd nof ba complafad if Iho work Invel d by MAIL
fh�permtf Is lor ono hundr�d dollars(5100)or le��.) LaVnTORY �q qooRE55 �
I ca�tify thot.in the performance of the work for whic rs � -
permit is Issued,1 shall not emplay any person in ony manner SINK G CiTv L� TEL NO.�,�'�
so os to become subjecllo ihe Workers'Compensolion Lows. DISHWASHER
. . CONTRAROR
pa�e � Appliconl CIOTHES WASHER qppRE55 '
_ NOTICE TO�APPIICANT: If, after making Ihis Cerliiicale of gyy��INGPOOLRECFPTOR
E.emprion, yov should become subject fo Ihe Worke�s' Cltt TE�.No.Z�b bn�
COmpensaf�on provisians o(tbe Labar Code,yoU mVst forth- {qydp�SPRINKLERSYSTE.M
with comply with such provisions or �his permi� sholl 6e STnTE y1 liC.
deemed�evoked. � � WATER HEATER UGENSE NO. . 7(J CLASS
LICENSED CONTRACTORS DECIARATION DISTRICT NO. PROCESSED BY
I hereby offirm tho�I om licensed�nder provisions of Chap�er 9 GAS SYSTEM OUTLETS � /v
([ommencing with$ettion 7000)of Divis�on 3 OF Ihe Business OUTLETS OVER �
and Professions Code,ond my license is in full force and affacl. - 5 PfR Sv57E�n FINAL VA IDATION
�] DAT�f� � p�.,�
License Number I��� Lit.Closs�_ O
, � FINAI/�+ U-
Comrac�or Date BY C� - �
❑ O.
I,am e.empr under Sec. V
1
B.�dP.C.tor ihis�eason Plon check fee , . ��
Date: pLUMBING PERMIT ISSl11NG FEE E �O S� Z
� Signature . �
TOTAL FEE o�L S .
. . . - � Plan check opplimm �
SINGLE FAMILY �
HOME OWNER-BUIIDER DECLARATION Nome � �� 7 O.�l A
1 hereby afiirm thai I om e.emp�irom the Contractor's license ��e« ft� � � � �F
tow far ihe foliowing reason(Section 703L5,Business and p�'---"
1 Professions Codej: City Tel.No � • �2�Jr O
❑ t,os owner o(the property,wil�do rhe work and ihe • o o,Z Q 5 O=
structure is not intended or offered fo�sale(Section , o
704d,9usiness and Professien5 Code).
CONSTRUCTION IENDING AGENCY . � O 9,� b—H 7
I hereby�fiirm�hat�here is a conzhuUion lending ogency for
rhe performonte o(the work fo�which�his permii is issued _ . . , . .
(Set.3097,Civ.C,). �
lender's Name .
Lender's Address
I certify that I hove read�his applimtion ond siare�ha��he , � -
above informo�ion is correct.I ogree�o mmply wiih all County � �
ordinonces ond S�a�e lows regula�ing Plumbing,ond hereby �
outhorize�represen� �ives of�his Coun�y to enier upon Ihe �
ab �c enYoned operfyfori-spection purposes.
SEE REVERSE FOR EXPIANATORY LANGUAGE
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