HomeMy WebLinkAbout0893A (4) WORKERS'COA3PENSATION DECLARATION �swse� .,, .�__ �
.:...,.
i hereby affirm that I ha�e a certifmate'o4consent�ttiself cEan(z-aa� APPLICAT.IO.N _FOR PLUM_BI,N,G,_PERMIT ,
_ ._ , .
irtsure.or a certificate of Norke s Compensation Tnsurance,or � '� � � '�� ' � � "� �-
a�certified cp py thereof(Sec.3800,L�ab C.}
W �'b�.p j�p<l_D!9 •. ` / ' COUNTYOFLOSANGELES.. BUILDtNG.ANDSAFETY
Poi�No. � CofipanY /�I/glflFL'_�/���^ .. .. . . .....:.. .. . ....
� � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT O�R TYPE) BUI�DING - �..
� � NUM6ER FIXTURE OR ITEM � . FEE '4�DRE55 L �� . f/Q
Certified copy is filed with the co ty building in ction
LOCALITY
� �.departmen[. WqTER CIOSET
Date �� �Applicant �'� NEAREST / �
� � � - BATH TUB CROSS ST. ,� LC
CERTIFICATE OF EXE1viPTION FROM WORKERS'
. � CO3SFENSATiON INSURANCE SHOWER I OWNER
. . . . . . .� . . . / MAIL }
LAVATORY y��%'
(This secYion need not be completed iP the woxk involved ! �� ADDRESS o
by the pezrtit is for one h¢ndced dollazs (5100) ox tessJ SiNK
. ,. . . . Q CITV TEL.NO. C>
I certify thnt in the performance of the work for which This DISHWASHER �
CONTRACTOR
pecm3t is issued,[shatl not employ any person in any manner , � � f/`�l �
so as to become subject to the W'orkers'Compensation Laws. CLOTHES WASHER qpORESS � y� U
Date Applicant - . SWIMMING POOL RECEPTOR � 6W.
NOTICE TO APPI.7CANT:If,after�inaking this'Certificate of CITY � TEL.NO. �,j�/j y
LAWN SPRINKLER SYSTEM �
Pxemption, you shou�d become subject to the Workers' STATE {� UC.
Compensation provisions of the Labor Code,you must forth- ,r�f � LICENSE NO. (p CLASS C`��
WATER HEATER �
«�ith compl7 wi[h �such provisions or this permit shall be " � DISTRICT NO. PFiOCE SSED BY
deemed reeoked. GAS SVSTEM OUTLETS �{q
� I.7CENSEDCONTRACTORSDECI,ARAT70N,.. . ..,�. OUTLETSOVER � �G {JGac17�--�
I hereUy affirm th5C I am licensed under provisions of Chapter � 5 PER SYSTEM
9 (commencing�vith Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professi�ins Code,and my license is in fuli force and DATE �p� g/��
effecf.�- - �
.�// FINAL
License Number��,✓/��Lia Class �`"�� } BY �
Con[ractor��J'r��Date�p��_S"" � /
� I am exempt from the ticensing requirem2nts as I am a Plan CheCk fee
licensed architect or a registered professional engineer pLUM81NG PERMIT ISSUING FEE S ��j'
- acting in my�professional capacity (Section 7051, Bus- '
iness and Profzssions Cnde). TOTAL FEE 'S y� ��'
Lic,or Re"g.No. - � � Date _ Plan ch¢ck applicani
H0�4E ORNF.R-BUILDER DECLARATION ,, Name
I hereby aff'u�m that I am exempt Ptom the Contractor's - Adtlress
License�Law for the foilo�+�in reason Section 7031.5.Busi- c C�y��
B ( City Tel.No.
ness and ProPessions�Code): � h a a a a�
� I,as owner of the properiy,am exclusively con:racting �
, with lirensed contractors to construct the project � a E.�.��(.''�
(Section 7044;�'$usiness and Yrutessions Cbde). � � �
e� r n�
- . , - . < ca L:...
,J�
- CONSTRUCTION LLNDI!QG A(UENCY. �, ;, _. __:' ,.,,,,�, .� , - �� �-�� � - � -- - - - ' �-
. . . . ... . . .. _ . .... .. ..._ . _ . . . ._ . . ., � „r,_r, ,
I hereby xffirm that there is u construction lending agency � ; �,�.,� �
for the performance of the work For whicS this,permi[ is ,
issued(Sec.3097.�Civ.C.). . . . . . . .. , . . . . . . .. . .. ...... .. . . . . . _ . .
Lender's Name- -
Lender's Address � �- � � - �
I rertify that 1 Nave read this application and state that tha � , � �� � � � ~ � � �
above information is w-rect.I pgree[o complS u'i[h atl County S6E REV ERS�FOR EXYLANATORY I,ANGti AGE �
ordinances and Stute laws regulating Plumbing, and hereby � - � �� � � �" � -
authorize represen[atives of this Co ty� to�enter upon the .
ubove-n Q`pro erty for insp t" ' purposes. . .
a � ,s✓' l�� �'���
S na ure o Yermittee f' te
, .���.,.�.-.a,va..�.4..�....,. ..„...M.....,........�__ -.._� . . ..:�„,.�....,.,�..s...............�
����..�,.us..�.�: . ...., . .. . -lN�P�CYdR'5�hI0TE5'...... ..�...._.....m._..,..... .... . .. . . ,
APPROVALS DATE �NSPECTOR551GIVATURE g_,�,�,__ � ��'����'$�S;..L7EI�,���'�LAEahTIC'6IO
UNDEP.SLA84VORK '
� � i e7ereoy at'Yirm tirae 1 s�r exem3d from che Co�rtrac±ac's
ROUGH PL'JM61NG ---- --------._.m-..__...,_..�_ �
-- - • �'3..�cee�;e'�a�: t'oz tha fciiawine rea�ort/SenP;or. 7C3i.5.
GAS PiPIIUG _ 3u�'iness ¢�:4' 73'OfeS&ions LiJQe/: .'isty ei7)' or Ccuttt�
Gqs'veNT� � ;vhich requires u perrnit to const;uct, aP!er, impros�e,
. . �. �..�..'. . � .
Herv�i�tesi�tieaTEa "� • � � � � � �---- � �� _..,�.�._....._... ���.de:nolish.or rcpair any xtructuYe,�rior to it; ;astennce,
'�AL'JMBING FIXTURES . - � - � _ e.'.4�J. l'e¢stlYC3 ti!¢ Q(3pitCtlY7 ju�T StACf1 perr.rt Pa filf tF
. . ,_,_,�_�_� �.cigi:zd�'cs2eermaFi �rhqr��?�e is fieensed yursuanr pU rhe
GAS TEST ' - � - � - � '
p:�zyisio�aa� of the Can;-racaor"s Lices.s� L.aw/Cbtupler 9
U7i�l i v Cp.NOriFiEo —_ � (ra�rtm�enrir.g>vith Section 'G7lQ/ aj�Drvision 8 cf rhn
� _ Fusi.aes5 6ItC'.N'GfP55•OMS Cedef or that 3te ix �xer,sp+
F,NqL ., , . theretra;r.�n,z zhe basis fo�lh.z atleged ezempr.'o�a..�1rry
�t2�vlt a4� �BOat.t � . . ��—��---�- vactati�n cJ J'ecr�on�7r31.,5 riy ary appficar,for a per;rait
' • . . . _._ s•.:e;ects th2 ap!t:icrer,;do c civil pevm(ty of'n�t rnore:h¢n
!NousTR6aL• � , � � . Jivehundre�do?lors,/55�3�J.:
WASTE APFROVAL � ' � � � � -- --- ---'—'—'- �F�•?S^`•,'"-r og?he pm�erty�viEf do t7ic woxk,and
� . !'r.e sEructuzc is noi in:er.ded oc oFfered fr�r sale.
... , . , . . . „ ' . _ __�_.___._.._.....__._..,..._ ;�'ec. 7044, &usiness ar.d Professions C7ade: The Con-
� ,, • , r;aceo>:s Liren.se Lcw dr�es not.zpp7y ta ax owner oJ
�' �� '� - � �• ' � � �_._� - fIY0;1¢YYj'.w':EG billl(!E OY 7.MJDYO!'L'S IDiC:20Ti,[171G x�ho does
, . , , . .ti .. ,. :ucr work kimseff.prcvided tha: suc'r. impr�vements
. -�� •-- ' � � � ' _ . . are nor rntznded or oj;ered jtir sale. :,t, howrver, ,•f;e
� � � _�� � � buiid+rtg er i�xprovemere rs sold wrfhi�F orre y�a� of
� �w�._�___�_......_..—.,__....__.,,...._ cempletion, tne.owner�builder wrff lea:•e.:rte barc'er:
.. . . .. , oj rro>ing.ahai he �id :�oz ba�i:u�or in�prcre fcr th�
, - . pterposa oj salz.;". ' . .
C am e;cemnt ni;der Sec.��..r=.
�' ,.?'_fnx this reas s�p '.;
_.... :, . ` _4 ;��. _F�..
�-8c A _
. : _ �.:' _ ._. _ ..
_ �ate ,,. _
4)wner�_
INSPECTOR'6 NOTES ��