HomeMy WebLinkAbout0771A (4) .,,�.._. ._...... _..___ _ .._ . __..._..T.. �
'"°RKE"s•�°'"°E"5"T'°"°E��R"T'°" APPLICATION FOR PLUMBING PERMIT � '
I hereby affirm�hat 1 M�e o certifimte of consent to aelf �ypyyaq
inauro,or o ceni4lcute of Workers Compensarion Imurance, CE B17(REV.10/H1) � � �� . i
pr a cen''a¢tvpy thereof(Sec.3806,1a6.C.) COUNTY OF L05 ANGELES BIIILDING AND SAFET1f
Poli w �''� CompanY��+�+-�-�r" . . . .i
� Certl#ied copy is herebY f�rnished. N01,ohQ"2.�, � . gU11D{NC � � �I
� Certified mpy ia filed with the uiYding'rn3pet• �p p�G'M ro FILL M�PRINT OR T`IPE) A�R�
Hon deportmeM. NUMBER Po7[7URE OR 1YFM � FEE ����T,�,, ,
Dote�-/�� qpplif,o � '� � WAlER Cl05ET � NEARE$T �
CERTIFIUTE QF EXfMP�O ROM� ORKERS' BAiH 7UB � tR055 St. . �
qDMPEN5AT10 SVRAIVSE S� pWNER �
(Thls s�ellon nNd not 6�eo � fahd�if-th��work imehad bp � , . . _ ���� � �
3h�p�rmft Is ior ene�hundnd dolloy(=100)er Iq�.) tqvaT02v
1 cemfy rhat in ihe performance of�he�work for which this , . . ��S , , �
�,permit is�uued.i sAalf not emp�oy arry�ptlYson 7n arty manner � . . Giv 1��.� i
�p as ro becama subjac��o fhe�Wa ,rhpenXafltl�laws. p���� � � � �� i
I�*' � CQMRACR7R ;
;�t���.�i.�a+.'. aPpli ` � CWTMESWASHER � . . .. . . � 1
TIOTIf�TO APPlIC;4NT: IF, e�� idng 'b��Gertifimte of � .. . . �� /' � i
�EkempTion. YW sh0utd bem aabject M thq NVwkerd SWuIANUNGP00lREGEPiOR OITv . ..fEL:NO. � I
�ymPeawtion pcpvisians of f �Roka.Ci�e�R�msN iernA- � V.W�SFkiratER stSiFiH EL
wi�h �amply wllh auth p isirn+s ar (hia pe[m�sbal}ba SrAiE IIC.
�deemed reroke,d. WpYEk HEqTER � ��g� N65 �
410ENSEDGONntAGrORS;DEC�nnkaTlON c,assrs�n p�,� , oisraicrNO. �rao�ssr�er
Q hero6y affirm�hut I,am Rcemed uadx provisioinsqft�o pter 9 '. .
��ommenting wNh Seaion fW01 of Qiv,lsi4n 3 t�1ha:6us�n�ss qit�75 pyE�t y �
bnd ProfC�ienSCbde,a�d:my(icen59 is�in fUll fpre pfld effeB. 3JER.6YSiEN1 FINA1 6
� �A� VALIDATION �
l,iceme Number-���'�4/. .tic.Cless�.�-.._ , U '
. . . .. . . � I Flh1A O
�Connactor�t?n;lrrr�/a�..��.t��f,,, �i4!l5aRC � � �
W
❑ I am exempt vndm Sec. , 4 �
� B.&P.C.for this romon � . � '-
Plan check fes � �
�0� PLUMBING PERM11 ISSUING FEE S
Signafurp 1� � �i
TOtAI�
i
. .. . ._ . ... ._. . �.
. . ��Plan check opPlicont . .
sir�c�F�wuir
MOME OVWNER•BUtLOER OECWRAt10N Name � . .
�hmebv alfirm tlw�I am exampt from the Contrac�or'slicnme . � � ' i
�Law for rhe following reoson(Sec�ion 7D31.5,Bvsinea+ond .Addreu . . . :-f;i�1 a � ;
Rofessions Code1: � d �Tel.No.
� �r Y 1
I,os owner af the propeny,will do the work ard fhe • • + �5 I
q
shucyvre is not intended a offered for scila(Saction • � � • �G C.Jr O
7044.Business and Rofemipns Coda). � .
CONSTRUCTION LENOING AGENCY .� . . � � . . . "1' "��,J O u.
I heraby affirm thot�hero is o construc�ion lending agancy fw � . � f
�he performance of ihe work for which this permit is issued.. . . � . . 0 g,� �`5 6 '
(Set.3097.Civ.C.). � . � �
. 1
LendeYs Name . ��
Lender's Address � � 1
1 ce�tify that I have read�his opplicatioo and s�ate that rhe . � � �
above inSwmalion is cwrecl.I egree ro comply with all Cpunly � •
ordi'ronces and Sta�e bws regulating Plumbing,ond here6y � . ;
eullqri ropreientofivea of this Counly to enler�pon tbe � � � � � � � � " . �j
ab tioned prpperfy for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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