HomeMy WebLinkAbout1765A WORK@RS'COMP€NSRTION D€CLARRTION qpp���q�`IdN' �t,�R PLUMBING REitMIT
I hereby affirm tha�I have a certificate of consent to self 76Ae67A ���
insure,or a certifica�e of Workers'Compensafion Insurance, CE 817(REV.10i81) �--�
�� or a certified copy thereof(Sec.39�0,lab.C.) COUNTY�F LOS ANGELES BUILpfNG AND SAFETY �
P❑olicy��r]��ompany Fremont Indemnity : �3
Certiiied copy is he�eby furnished.
' � FORAPPUCANTTOFILLIN(PRINTORTYPE) BWLDING�! h �F�� �
.Cerlified copy is filed wilh the coun�y b�ii ng inspec- ADDRE55 14' � ��.-
� fion daparfinent NUMBER FIXTUREOR ITEM �r,2 FEE �OCAUTY
oare ti��Q��S i;a„r waTea aoseT
�-App 4 . �� NEAREST� � 1 l�S &.I1C
CERTIfICATE OF EXEMPTION FROM WORKERS' sAiH TUB CROSS ST.
� COMPENSATION INSURANCE SHOWeR OWNER South Gountr COT
(Thic s�ctian n�ed nof be eompls�rd if fh�work inrolv�d by MAu - .
�, fh�p�rmit is 1or on�huodnd dollan(f100)or In�.) LaVnTORY / ADDRESS
I certify 1ha1 i the performonce af Ihe work for which this
''� permit is issued,I shall not employ any person in any manner SINK — CI7v TEI.
�. so as to becoma subject io the Workers'Compensation Laws. DISHWASHER _ !
� CONTRACTOR��C.R. Pltunbin � INC.
�. Dafe opplicanf ClO7HE5 WASHER - ADDRESS
f�QTICE TO APPUCANT; If, a£ter making fhis Certificate of 127$5 Ma nolia Ave.�
� mption, you should become subject to �he Workers' SWIMfAMGPOOLRECEPTOR . . .
` .mpensation provisions of�he Lobor Code,you must fonh- � CiTv iel.NO. _
U1WN SPRINKLER SYSTEM •
� with comply with such provisions or �his permit shall be STAiE 336428� "`� C-36
' deemed revoked. N'ATER HEAiER LICENSE NO. CLASS
LICENSED CONTRACTOR$DECIARATION DISiR�C7 NO. PROCESSED BY
I here6y affirm ihat I am licensed under provisiOns of Chopfer 9 GAS SYSTEM Ly OUTLETS
(mmmencing wifh Section 7000)of Division 3 of ihe Business OUTIETSOVER � '�'"
and Professions Code,and my license is in full force ond effecl. 5 PER SYSTEM F�NA� "
oare I Z�a/�S 5 vnu ATION �
License Number �3.6..(�'�.$ Lic.Class �_��_
�.'.
co�,,a�,o� RCR Pluinb ing oOfe 6/19/8 5 8Y AL /��� p
❑ I am exempl under Sec Wj
�7 .
B.&P.C.for this reason Y., -
Plan check fee F 1 7 G 5 A
�afe: I
PLUMBING PERMIT ISSUING fEE$ �G' .[G � • • • •�5
$igna W re
TOTAL FEE - n/ �� -� �s�7 Q rJ�
�'F'
Plan check applicanl
SINGLE FAMILY •�-• •I Cl J�O c=
HOME OWNER-BUILDER DECLARATION Name .C.R. ING, . INC..
'�"reby affirm thot I am exempt from the Contrac�or's License e, �7,2 9`8 5
. "%F for the following reasan(Section 7031.5, Business and Address . �
��Professions Code): Ciiy � Tel.N
. ❑ I,os owner of the prpperty,will do Ihe work and the � . �
structure is not intended or offered for sale(Section �
7044,Business and Professions Code}.
CONSTRUCTION LENDING AGENCY
I hereby affirm that�hefe is a construction landing agency far
the perfo�monce of the wwk for which ihis permit is issued
(9ac.�,Ci�.C.). �
L°eride''s Nertt�
� ter�r�s Atrdtes�s �
I cerfify thot I hove read this dpplimtion ond sfale thot fhe �
above information is correct.I agree to comply with oll County .
ordinances and State laws regulating Plumbing,and hereby
authorize representatives of this County to entar upon the
obove-menfioned pro e`fy for inspe on purposes.
SEE REVERSE FOR EXPLANATORY LANtiUAGE
R_�'-R.�_l���id�'�yL],�-�`�—
Signatura of Permi tee Daie
, F ��. y . # _.
1 �
�' � �`' _ s � ' '# . . .. 1 • � _ ��
- APPROVALS DATE IN PlCTOR'SSfGWAiURE WSPECTOR'S NOTES OWNER-BUILDER DECLARATION
UNDNt StAB WORK 5 I hereby affirm Ihot I am exempt from tne Contractor's
ROUGH PLUMBtNG " � Licerse Law for ihe following reason (Sedicn 7031.5.
GAS PIPING . p � Bvsiness and Professions Code):Any city or munty which
GAS VEfJT � requires a permJf to cortstrud,aHor,improve,demolish,
or repalr ony slructure, pNor fo!fs issuance, also�e-
HOT WAT2R HEkTER
quiFes ihe applicanl lor such permit 4o file 4 signed siate�
PLUMBMJG FlXiURES ment Ihal he is licensed pursuanf�o the provisions of�he
Gt.5iF5i ./ � ;rf,�'.- . Contracfor's License Law(Chopfar 9(commencing wit6
UTILITY CO.NOTIfIED Setfion 7000)of Ofvisdon 3 of/f3e Business ond Proles-
, sions Code)cr 1hW he!s exempf lherefrom und the besis
n � � for Ihe alleged exemption. Any violcflon of Set�ion
FINAL , GRfer om �rortt � 7031.5 by any applicont for.a permit subjecls!he oppli-
- conf to a clvil penolfy of nof more than five hundred
dolfars(S$OQJ.:
INDUSTRIM ❑I,as owner of the property will do the work,and
WASiE APFkOVAt � - - the structure is not intended or offered for sale. _
(Sec.7044,8us7neas mnd Profescions Code: The C� c-
. � . � � � .� }or's L(tsrtse Law does nml opply}o on owner of prc� Ny
- wha bvilds x impvoves fhsrear�, and who doss such
� � work himse7f provlded that such Improvemen�s we nof
� Intenc#bd or offdred fbr sal�.If,howaver,the 6uilding or
lmprovemen#Is sold wlkh{�p�y�01 complaficn,fhe
own�rvbulldar wIH frevs tha 6wdwn of proving fhaf he did
nol baild or improw f�r fhe p�epose o!sa(a.)
� . , I am oxempt under Sec.' �-- � ,
� 8&P.C.for}his reason
' _ Date
Owner
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IhdSA�C'fOR'S NOTES