HomeMy WebLinkAbout1120A � �
WORKERS'COMPENSA7IONDECLARATfON �e�e��a � APPLICATION FOR PLUMBING-��PERMIT ///777
1 hereby affirm that 1 have a'certiYcate of consent to self ae en(x•so y�
insure,or a certificate of Workers'Compensation Insurance,or . ��
a certi�ed copy thereof(Sec.3800,La6.C.) , LJ
COUNTY OF LOS ANGELES BUIIDING AND SAFETY
PNicy No. Company � . .
� Certified copy is hereby fumished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING (� .
ADDPESS �'(, p� �Ur�
� Certified copy i5 filed with the county building lnspeclion NUMBER FIXTURE OR ITEM � FEE
department. WqTER CLOSET LOCALITY � .
Date ApDlicant NEAREST
BATH TUB CROSS 5T.�–y, �� � �
CHRTIFICATE OF EXEMPTION FROM WORKERS' LL
COMPENSATfON INSURANCE SHOWER OWNER � � a 1�(C I`
LAVATORY MAIL '`,, }
(This section need not be completed if the work invoived qoDRESS �p,W�V� �Gl al i�� Q
by the permit is for one hundred d011us (SI00)or less.) SINK . CITY �� TEL.NO��`���5 U
1 certify that in the performance of the work for which this Di5HwA5HER �
permit is issued,[shall not employ any person in a y qi anner CONTRACTOR � �e� �
5o as t ie m¢subject to th otlFe s' q17M1 �o Laws. CLOTHES WASHER ADDRE55 � - - U '
�at� Applicant V SWIMMING POOL FECEPTOR d
NOTICE TO A PLICANT:!f,afler making this Certificate f CITY TEL.NO. � v7
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYS7EM z �
Compensation provisions of lhe Labor Code,you muat torth- I s7aTE `_ LIC.- ._ —
avi[h comply with such provisions o� this permit shall be r WEITER HEATER DO LICENSE NO. CLASS
deemedrerok�d. GASSVSTEM OUTLETS OISTHICTNO. PROCESSED$V
LiCENSED CONTRACTORS DGCLARATTON OUT�ETS OVER �O p
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7D00)of Divlsion 3 of the Busi� OATE r� �� �Z VALIDATION
ness and F'rofess�ons Code,and my Iicense is in full iorce and
effect.
FIN L �
License Number Lic.Clast . 8Y
Contractor Date
� 1 am ezempt Crom the licensing requirements as I am a Plan check fee - �
licensed architect or a reglstered profexsional engineer pLUMBING PERMIT ISSUING fEE E �j
acting in my Frofessional capacily (Section 7051,Bus-
iness and Professions Code). TOTAL FEE �p� Q �� � 2�A
Lic,m Reg.No. Date Plan check applkant -���� ��� �Jr �
FiOh1F.OWNER-BUILDER DECL.IRATION Name ; Q C I • • , 2,�j 0
I hereb affirm that I am exem t from the ContractoPs Addresz y �/�
. Cirense Law fur lhe tul�owing reason Section.703L5,Busi- / . °.� n � 2 5�u �
� CitY Te�.No., S
�ness a d Protessions Code):
as owner of the propttty,am ezclusively contracting � r Z 2 4`$�,
wi t h li c ro s e d c o n tra c to r s t o c o n s t r u c t t h e projec t
(Section 7044,Business and Pro(essions Code). �
CONSTRUCTION L]iNDING AGGNCY . '
1 hereby affirm that Ihere is a construction lending agency
far the performance of ihe work for which this permit is
issued(Sec.3097,Civ.C.). .
Lender's Name ' �
Lender's Address - �
I certify that I have read this application and state Ihat the
above information is correct.I agree to comply�vith all County SGL•REV GRSE FOR EXPLANATORY LANGUAG£
ordinances and State lawg regulating Plumbing, and hereby
authorize representatives o this County to enter u0an the
abo • eMio ed p Iop�tJy ns�eclion pu`p�es���
� V� I t
Signature of Permittee Uate �.
� �, c� o z
C � { O� N �' G � v
-n a v � ` G .� ? m
� v
�Z Z � � c� ➢ m 'O .� N �
a 2 `z c� r o
�, y c
. . '{O . r O �{ � �1 � � 7 G �
T S' P L U�
X m
qD O G T'-a Z 9
o� T � m� � x
� -- ra °. o
. �"'�' . ' c�' � � v�
+. �y � , , m .
.J . C�
�-. -�' f�
CJ `� � -^ - . � �
1 ,!> • � . . ,�o
^ • , y� �
, 1/ ~� '� b , , - � ��/1
. �� � . . �. N .
� � L
. � . ➢a .
cn . C
p . , , m
, m , � •
N .
. �
�
�1
i . � '
� . �
. U
' O
• - a
.. • in
N
, � , � �� �
� . .. r �� c���ou_o`-er_� ` � �
� �.c '�<� "C;'.--.�� �c ,.� ^.c� c.� :. n
� c� p r, �. �Q� .�. G r_ v, o •o .�
.� C^G _..'+ ...'c O'":, �t. Y�C v s.�• .' ^ `^ �� L�
' � ,�.�.... C:c : v y�,,u', r..' i''�-,p G�' ...1_ ^." n� % �i
_ � Vr C C �,' r. O � ^s' ^ --T v✓ '^ � �.=• ^'�, �'
� ' Ce �' L r ^. -Y :'n ~ �`� �, l4 r
. G �� ' o �'o � � r�o%'��r l C�'. n° - r�_ c� r `� '� �
p � r, � ..-.x . " � �� �` � cn� � ^Y °� �
, % n 'r'� rf'+ £� `. ='^:.�Yo _ �„ v.�'��� � � ��. ;;�, c 7
� . � ,,.� .�'Ji „�c''.r'o ��'..n'v�'^'� �'^in� �,^,;�� -� ^a n C n`.+•% l�J
. � , . ~ .� � �,,. C � -v ,V �� T 7 f. O C y�� C'1~ � ^ f•fY � r
' . i � � - � C:�Gq�-' n O ou'._C �-. =`� �
, . . �. � �1 � C y O `C�• ..'v G C L"`�~ :V v. —V � .
�� . � , �f, .:C -Y �� {�:p e+'.-O �. ^ .p � . ' � N
' c�' t �' ' C ^ L ' o e� '� ._
•�v J
. t� Ci� r�'G'C"O� C`,p-. f-'v_ "� h„� ^'o.'� q " i�
. • J ('� � ... r.� fa v� '� p.G?a �. lC �,,,�'O � (� ,�
� , p n �, �� � � e: ...b o ^ .
. , , _ c C � a c G'� "' i; �� �. � - C r= �' C C `L
. � , 4 T. � r: _� G c t� N. :� : = v. 'O � ^
. ' �. C" r�~ G �-..n _ r' , c o � �
� . . . . � • ' ^ � C �� i �--n•p �.`� C"•^'C i, �' C G n
. , Gi �. •p :�, G .O, „' li'€'i �T' C .w..G
. . � . . ^' � ^.� _ o G � C � ^O��' O 3
� ` in
. . •O C p^ C" C ..y O �'pC n � �a � ''� ��
. . , ' • � . O �ic YO % ;� T _:'' � ,a"'. s'
. • f: ,� . C iu ('� � P^.:�-,
, . O C�ri � a� C ` �
. . -i ^' - O♦ C,^
.. _ . , V^, ���'
. �