HomeMy WebLinkAbout1627A (15) �
"'°RKE�•�°""�"5""°"°E�aR"T'°" APPLICATION FOR PLUMBING PERMIT i
I hereby affirm�hat t have o cenifiwte of consen+to self �yqbp�q '
ina�re,or o cer�ifi�yte of Workers'Comper�wtion Insurance, C18�>I�.l0iel) � - .
or a certified wpy thereoi(Sec.38W,1a6.C.) i
q���,� COUNTY OF LOS ANGELES BUILDING AND SAFETY
p❑olicy No�/�-1 JG Comparry� . . �
Cerlified copy is hmeby fw�ished. J i
� FOR 11PPUCANT TO Flll M�PRINT OR IYPE) B�pR� I m H �
Cenified copy is filed wilh!he ty Jding inspec- .
tiondapOrfinent." NUMBER FI%IURFpRffFM � iEE
L(ZCALITY �� J . I
Da1��Applir,nnl / / WATER QOSET NEARESi '
CERTIFICAIE OF EXF,AM1PTION FROM WORKERS' BATFi NB CRO55 ST. i
COMPENSATION INSURANCE S��R Owr�R G't�' O i
(This weFTort e��d not b�eomplebd(f th��rork Involv�d by �� �
ths pe�m(t is For ons hundred doilan[5100)or lats.) �p�A�y qpp�u � 3
I cerrify thot ia�Fe pehom+<mce of rhe wwk tor which�his � - -
permi�ia issued,I sha11 not employ any penon in any manner �' �K . . . � O p qTv� , tEl.N0.
so m ro become nubject to the Worken'Gompenaation Lawa. oRefwA�FR � � /J
�IJTRACTOR �
Dcte °PPlicanl 40tMESwASHER .
NOTICE TO APPLiC/1NT: If, oher moking tAis Certificare of A�E ;
Exemprion, you should becoma tubject to the Workers' SW�������
Compenwiion provisiom of the�obw Cqde,you must forlh- �qyyry Spp�NKLEN SVSiEM aTM �0 ���� �
with comply wi�h such provisions a lhis permit shall be `�� ^�� v/_ li�s _ .�
deemedrevoked. � � WqYERHpqiHt NO_7 �CJ
UCRJSm COnrtRACTORS DECLARATION . d� w5micr roo. BV j
I hereby affirm�hpl I om litgiped under provisiom of Chapfar 9 �S�M �T� �� } �
(commerrci�g with Secrion 7000)o(Division 3 of tf�e 8usiness pUryElSpyER - p,
ond aofessio�s code,ond my license is in full foroaa�d effect. fl s�s FNa� VALIDATION O
License Num6er � ic Claas� r Q� �O AATE ,�t v � � 1
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//J�/��N/' . flNAL O
Contraclor�C • �^'W977 ��� . . � BY W ,
❑ I em exempt under Sec. � � �
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a.av.c.r«m+s�eaw� plon check fee i �
i
��e� � PLUMBING PERMIT ISSUING FEE E D - fi 1 6 2 7 A �
sa�a�.e Touu� � 60 . �
. #�. . . . .5 i
� - Vlan chack applicont i
51NGtE FAMIIY ,� • •5 2 5 0
HOME OWNER-BUILDER DECIARATION Nome • • .�2;O U �
1 hereby affirm iha�I am exempt from ihe Conbatror's License .
Low Fa flw followtng raown(Sacs�on 7037.3,BuGneu ond '��fQ� . ... . ',
Profession:code: a'Z 1 7-8 4 '
) City Tel.No. . �
❑ I,as owner of�he popeny,wiil do the work and rha , �
strucrure is�ro�intendad w offered fo�sale(SecKon � � . . � �
7044,Bueinese and Profnsions Code). � � �
CONSTRUCTION IFNDING AGENCY . � � . ' � .
I hereby affi.m thot ihere�s a conntruuion lending agenty for �
the perfwmnnce of the work for which this permi�is issued . , . . .
(Sx.3097.Civ.C.). �
j
Lender's Nome � �
lender's Addreu � . . .. )
I cer�ify tho�I hove read this opplication and s�a�e that the ` � � � j
above i�formation is corcect.I ogree�o comply wi�h all Coumy .
ord7nances and S�o�e lows regula�ing Plumbing,and bereby � �
authoriz presentoiives of fhia Coumy ro eater upon�he �� � � - �
ahove ion property for inspec�Fon purposes. ;
SEE REVERSE FOR EXPLANATORY LANGUAGE I
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