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HomeMy WebLinkAbout1612A (9) _ ._._ ____.. _ - -— _�_ . _ _. ._. _. .�. _. ____-- _ _ . _:. . _ ,._.._._ __ _ ._ _ _ ..__. _ __. r._.......... __. ; . . V.'ORKENS'COMPENSATION DECLARATION �s�sow � � he�ebY erf�m that I have a�a«;�,�e�e of�o��,�to��f «.���=-.o, APPLICATION FOR PLUMBING PERMIT � lnsure,or a certificete ot Workers'Compense[ion Insurance,or � j a cerlified copy thareof(Sec.3800,Lab.CJ •/ . � , _ _ 4� COUNTY OF LOS ANGEIES BUILDING AND SAFETY Policy No. Compan . . . . � ,� Certified copy is heteby lurniehed. - FOR APPIICANT TO F�LL IN(PFINT OR TYPE) BUIL�ING� ADDRESS ' , � Cartifad copy b filed with the�unty bu'iding inspection NUMBER FIX7URE DR ITEM • FEE LOCAUTY � � me . WATER CL03ET Det Applican[ NEAREST . � � ' � BATH TUB Cfl065 ST. � � CERTIFICAT£OF EXEMPTIO ROM WORKERS' � . COMPENSATIONINSURANCE SHOWER OWNER � � LAVATORV � MAIL - CI'his sectlon need not be completed if the work inroived - � � � ao�Aess . } ; by the permit is for one hundmd doilus (5100)or IesaJ S�NK ' � � pp� a� CITV TEL.NOS/p-9 O � I certify that in the performance of the work for which this DISHWASHER ' U� �.. permit is issued,I shail not employ any person in any mannel CONTRAC70F � so as to become subject to the Wo�kers'Compensatton Laws. CLOTHES WASHER qDORESs `O �('� O � Date � Applicant SWIMMING POOL RECEPTOH - U NOTICE TO APPLICANT:It,after making Ihis Certificate of GTY � TEL.NO.yy��DJ W Exem tion, ou should become su6ect to the Workers' LAWNSPRINKLERSVSTEM � �' p y J STATE Q� L10. tp . Compensation provisions of the Labor Codq you must fodh- � LICENSE NO. /O !' CLASS C.�3 Z with�comply with such prorisions or this permit shall be WATER HEATEFt � deemed revoked. GAS SYSTEM OU7�ETS � DISTHICT NO. PROC SSEO BY ��� LICENSEDCONTRACTORSDECLARATION OUTLETSOVER ! � 4,[.c.l�/ I hereby affirm that I am licensed under provisions oC Chapter 5 PE R SYSTEM i' 9(commencing with SecUon 7000)ot Divixion 3 oF the Busi- ' � FINAL�t� �� VAUDATION ' � ness and Pro[sasions Code,and my license is tn fuil force and DATE ! - effect. f�-�' � FINAL ! License Numbe � v l.ic•Ciass �� eY � A � � � i�q Contractor Dete y � � 1 , � � 1 am exemp rom ihe licensing requirements as I am a Plan check fee � . ��y� y licensed arehitect or a reQistered professional engincer pLUMBING PERMIT ISSUING FEE S ` �'. acting in my profeasionai caDacity (Section 1051,Bus• � ���� iness and Protessions Code). TOTAL FEE ti� � [ Lic.or Reg.No. Date Plan check applicant � � ��1 �� Namo � . . . . . . . HOME OK'NER•BUILDER DECLARATION � � f�.(�'�.'Z Fl f� I hereby affirm that I nm exem0� from the Contractor's Addrou . � � � � � � License Law for[he foilowing reason (Section.7031.5,Busl- Ctty Tol.No. - - �� � � ••'� ! ness and Professions Code): t � I,as owner of the property,am exc�usively contracting � � � � 2 5 d � with licensed coNractors to construct the D�oject � � ��,• • ��2 J r,�u . . (Section 7044,Business aod Proteasions Code). � 0222-82 CONSTRUCTION LENDING AGENCY I hemby affirm �hat there is n[ons[ruction lending agency �� for Ihe performance of the work for which this permit is . � ���, issued(Sec.3097,Civ.C.). , - Lender's Neme . r LendePs Address � � � I rertlfy that 1 have read this application nnd 5[ate that the ��. ,� a6ove information is correct.I agroe to comply with all County SEE REV ERSE FOR EXPLANATORY LANGUAGE � � �- -- � ordinances and State laws regulating Plumbing, and hereby � aulhorize rapresentatives of this County ta enter upon the , . . _. _ . . . . . -- above-me ed pro etty for inspection pur oses. ' � � ' �"°"�'�.� a��/.� Signature {ermittee Dale � . . C , APPFiOVALS �DATE� INSPECfOR�55IGNATURE � INSPECTOR'SNOTES � � ' O{�'NCP-GUILDGRUF.CLARATION . UNOEq SLA6 WOFSK -� - - . . ' - � ' ROUGH PLUMBING � I I�L`rCL)'aSfirrtl th�t 1 Cm e�cmpt(rOm�l�C COn[iaCto[S � I.i�:en<c i.aw tor Ihe F<��torving resson(Seetiort 70.?I.S. , GASPIPING -� �� � � � � � "• �- - � - � � ' ' ' B;�Sirt�S.S cnJ f'rojes.cions CadeJ: ,fny� city or countv � GAS VENT � � �� � _. � _ ._ �� . �chich requires a perririt tn consrrucr, clter, in:prore, , HOTVlATER HEATER � ' �. dCn7olich,nf fepCir on)•S�rs�cfuiP,pI(or!n!is ia'.Si1c�iCP, � ?LUM1I6INGFIXTUFES- ` - • -- � �� �� ' . . Clso reqttirc.s the aJ)j)licartf for J�tch p('rnii! !o file o � . .. aiencd�statcir.e��t thai hr�i,t licensed�p++�sr�ant�.�o 7hc � cas^resT � . � � � prorisia�s of tl�c Cairrcrmr's I.tccrrse I.a�v(C7eaprer 9 U71LI7V CO.NOTIFIED ' � (ro�nn�eir[infi witlr Scclion 7000J nf�Dirisimr 3 of thc -.- . __ . . _ ._ _ � 6usinerr aird 1'rofersionr'CodeJ or nc�t lie is exernpt - -- fhc�efrnm mrct dtr hesis jor fhe a;lCged exeprption,Am• FINAL._ . ��jy p�{. G�Zp�gt' . . - . . ','eioletiorojSertion7031.Slivmrycpplica�:tluraPermit , � , � � suLjec�s the applicmit io a ei��i!penc(ty of not more titarr INDUSTRIAL� , . „ , firc 6itndred r:n77ors/SSGOJ.: , WASTE APPROVAI - - - . . � ' ' ❑I.as owner of thr propefty�i'il!do tlie u'ori:.an� . � . . � � the structure is not inl:nded or of(crcd fur safe. . _ ' " " . � � _ �� - /Sec. 70�F4, R:uinesa and Prnfessions Code: Tl:e Com . � � , ._, ' -� , � _' _ _ � � '_ ', ' _�_ � trattor's I.ire�rse Icir docr�mt apply�to mr owtter of - �-� � � � � �� � - �irnperty xho Luilds or i+nprores lliercon,mfA 5��1m doer - . , . . . - -- sucf: n•orf. Lrn�rclf p-ovided (hat stidr improremenis � � � � -- -• ��-� � -� � � � are nnt irr7encJed or oJfrrrd for scle. Ij, iioivercr, thc ' " ' � � - ' � ' � . , , , . _ b:eilding o� im,�roremeru rs sofd ioidti�+ aie ��ear of . . � � • � � m�npletio�r. the mvaerh�d/der n�i!! l�nvc Nre bender� - .. ' � .. - ---- . .. . � . .. � , . of proving rl:cr he did i+ot build or Lnprorc Jor 8re - - . - purpose oJ.rara.l � . �� � , ..� � . . .. - �,._�-. - . . . I mn exeript under Sec. , " .'L`S P.C.for this nstion �" �' ,'4 iJ f. . ' ., . . ' , .. - . `:''.!y.' . . . . _ . ' , 'a`, �,.., . ' . . _ . . ll�te , " e.ia:�f rdr.''�.. Owner rT «., `��.`.�;;'•F� `,.. .. .. . . . ' . . , , . f.` rINSPECTOR'SNOTES T�'� �. " � . � ' � ". , I �� � ' . . . ., • � I 7i� f• V � ,r , � � , ;--_ �J � . i