HomeMy WebLinkAbout1777A � C MV�W9,4TiCN%6ECLAV2ATION APPtICATION F4R PLUMBING PERMIT
I hereby affirm that I have a certificate of consent ro self 76n667a p�� `qqq �
insure,or a certifimte of Workers'Compensa�ion Insurance, Ce ei7(aeV.�Oiat) �
or a ce��ifad�oPY rh�,�f�s«.�,�ob.e.� COUNTY QF 40S ANGELES BUILDING AND SAFETX
P❑olicyj�.$�$�ompony Framc�nt TnAamnity ; '
Certified copy is�hereby furnished. a
� FOR AP%,ICANT TO FILI IIU(PRIN70R TY7E) BUItDING- �j �7�y��
.Cerlified copy is filed wifh ihe county building insp� AD�RESS�6'.�7 .�y(f�C,.C,d�CC_,_
�ion deparimenf. NUMBER FI%7URE OR ITEM �ro FEE �OCAtITY amon 8Y
WAiER CLOSET
�. Da1e �+��Tq�R S qPPligant NEAREST i ips Ranch .
� CERTIFICATE OF EXEMPTfON FROM WORKERS' eaTH 7Us CRoSS ST.
COMPENSATION INSURANCE OWNER 5outh Country Corp.
(ThF�sectWn m�d rror 1»eomp4Qt�d if th�work inwlvad by SHowER
' 1h�p�rmN is for ons hundnd dolfon(5100)or I��t.} � LqVA70RY MA�t P_•�. BOX 3329
ADDRESS
, I certify ihat in the performance of the work for which Ihis
permit is issued,I shall not employ ony person in ony monner f SINK _ CIiY Covzna TE��N�67-9541
so os to become subjecr fo the Workers'Compensation Laws. DISHWASHER � � �
coNrRncroeR.C.R. Plumbin N
Date Applicanf � CLOTHES WASHER � � � �
, f�7TICE TO APPIICANT: If, a'ter making this Certifimte of AD�RE55 �
� _ �nption, you should bacome subject io�the Workels� SWIMMMG POOL RECE�TOR _ . .
....mpensolion provisions of�he Labor Code,you must forfh- qTY TEL.NO.
� with comply with such provisions ar �his permlf shalf be �kWNSPRINKIERSY57EM STATE • o[• tIC.
deemedrevoked. WAiERHEATER � IICEN5EN0. �JU4ZS CLASS C-36
. LICENSED CONTRAC70RS DECLARATION DISTRICT NO.�� a20CE55ED Bv
I hereby affirm�hot I om licensed under provisions of Choptar 9 GAS SYSTEM OUiLETS — �
(commencing with Section 7000)of pivision 3 of the Bosiness OUiLE750VER �
5 PER SYSTEM �
, and Proiessions Gode,and my license is in full force and eHect FINAL
- License Number�.8.—lic.Class��_ DATE rl �'/�i� ALIQAflON �
co�„a�,o, RCR Plwrib3n�oore�I19I SS BYA` �4t'.+�"'�✓' �
�t;
1 am exempf under Sec.
�
B.BP.C.for ihis�eason plan check fee � '"'
Date:
' PLUMBING PERMIT ISSUING FEE$ �p 'O � �� 7 I,7 F�
Signalure
� TOTAL fEE �'�.�'"a �=< • •�� •5
Plan check applimnt ' • •'�Q Jr O
SINGLE FAMILV
� HOME OWNER-BUIL�ER DECLARATION Name I G, I �+', . r
�� ��eby affirm that I am exempl from the Controctor's License ��,�°�.gIT�S��'cf� , � 9 �7�5(��'
' far the following reason(Section 7031.5, B�sinesa pnd Address . O�2 G j 8 5
� Professians Code}: ���Y
� . �,$��e Q Tel.N
I,as owner of ihe p�operty,will do fhe work and fhe .
� strocture is not intended or oHered for sole (Section ' ►
7044,Business and Professians CodeJ. ,
CONSTRUCTION LENDING AG€NCY
� �here6y affirm that there is a construction lending agency for
� the performence of fhe work for which ihis parmil is issued
� (5ec.3099,Cir.C.}. �
�'s -
Lerdas's Aadeesv----
' I certify that I have read this applicalion and sta�e ihat the �
above informa�ion is correct.I ogree to comply with ali Counly �
� ordinon<es and State laws reguloling Plum6ing,and here6y
� authorize rapresentotives of Ihis Counry to en�er upon �he
obove-menlionad pr ty for in lion purposes.
f � SEE REVERSE FOR EXPLANAiORY LANGUAGE
R.C.R. BY �U�,�Q 61?31s5
�� Signafure of 7ermitt�e Date
� _ —_
AWROVALS AT'c INSRCCTOR'SSICiPoANRE �hS��OR�S NOTES OWN2R-BUILDfR D�CI.A�feTIORI
UNDER SLAB WQRIf S �S� ('y�� � I hereby af4irm that i am e ampt from'iFe�Contractor's
ROUGH0.UMGNG �d �(��c,"" -�,��� License Law for the followng reason (Seclion 7�73)S,
Ga5 PIPING �,�'.�a'- � • Business ond Professians Codz)�Any city or county which
GAS V€NT
reqWres a permi�to construct.alter,improve,demollsh,
HOT W{yTER HEATER or repair ony 5}ructure, prior fo it, issuance, also re-
'qu7res}he oppficanf for such�ermit�o lile b si�ned sfa�e-
PLUMB{Nf FlXTURES mont fhat he is ficansed pursuant fo tMe provisions of hFe
GASTEST :�G" ��'>[,*{ � - Contra[ior's Licensa Law(Chapler 9(commencing wifh
Sectton 7008)of Division 3 of�Fre Bus�ness ond Profes-
11TILRY CO.MO71FIE0 � s7ans Coda)oF thaf M Is s�rew+pl iF�areNorn and iha basrs
. f ' for ihe alfeged exemphion. Any vfofafion of Section
FINAL - f nfer ort �ronl . . 7037.5 by any ap�slicont fer c parreit sub�'ects the oppl!-
cant to a civtl penalfy o(not more fhon�ive hundred
� . dollaro($500).:
iNDUSTRIAt ❑I,as owner of tha properry wlll do the work,and
WASTE A?PROVAL the structure is nof intended or cffered for sale.
(Sse.7044,Buslness ond Pro(ecsions Code: The Cr
. - . tor�Lleenss Law does nat�apply ta an owner ol prop.,rty
� . � � wha builds or lmprows fhereon, and who cbes such
. = work hFinaelf provided ihoT such improvements ore not
� � )nfertd�d or offwed itr sole.If,howevx,the buffding or
IrnprovemerM is soFd witMin w»yeor ol complefion,ihe
nwnar-bu7Wor wi0 havs iAe burdvsi of p:oving Ihaf he did
� � nof lwfld or improve for The purpose of safe.)
� I am exampt under Sac. - ,
B&P.C.for this raason
Date �
# Owner
iNSPE�TOR'S NOTES —