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HomeMy WebLinkAbout1105A (5) W°RKER'•�°^^�"S"T'°"°E«ARA"°" ' APPLICATION FOR PLUMBING PERMIT I heroby,offirm �hai I Fwve a cert�fkote of conswr ro wlf 78A6B7A � . - - � �� insuro,or a cenificate of Worken'Compensafion Insurance, � CE 817(REV•B/B8) .-� " , - ��" � . . .. . . ' w a cern4iad to�t r o 5�a 3800 b.C.J � . . _. . � . . - i �'j$ �-�/ �' F COUN7Y OF LOS AN(1ELES .— pE�P/T.��.O/�� PU8 IC W KSQJ POolicy No. Compony � . .7��717�. � .�-�� Q � - , Ceriified wpy it hxa6y furNshed. � � � � , �� FOR APPIICANT TO FILI IN(PRINT OR TVPE) �����' �� Certified copy��filed with the counry buildmp Intpsc• ADDRE55 D �. b� !�J�{on depar�menL � NUMBER flMURE OR IiEM � �E �p�qIITY. �� �-Da�e`-'�Appliqont s wnme,noseT � � Io`Z Op NEnrtEST . . � � CERTIFICATE OF EXEMPTION FkOM WORKERS� �TH�e � ���' � � '� � - � COMPENSAT�ON INSURANCE � . OWNER .. ° ' � � (Thls s�efton nNd eo�b�eompl�t�d II th�work i�wdv�d 6y SHowia � - th�p�nnit Is For on�hundr�d dollon(5100)or I�aa.) LAVATORY . I ��L � -- . . . .. I cer��fy�ho�in ihs performancs of�he wwk for wh�ch�h�s . ��� ' permlt is iuoed,I tMll no1 employ oey psnon in aoy monner .�� S�NK CITY� . . 8 r � ., - so os to 6ecome subject�o ih�Worken'CompenwNon Lows. -' DiStiw�Sh�eR � . �� conrra�croa I P � ppfe ' �PPlicaof - � CLO7HE5 WASh�ER y� I NOTICE TO APPIICANT: If, nfter makiny �Fis Certifimte of '�E�'� D7O� S'ryn Q . . �i ,�•emption, you shauld become subject to the Worken' SwtMMnaGq7pLRECEvfOrt /+ ,: � n ansa�ion ovisiona of the La6or Code,you must forlh- ��TY lo a ' Q P p LAWNSPRINKtERSYSTEM I ���..�h comply with sucA provi�ions or lhis-pxmit shall be STw7E ��O p ��C d�emed rerokpd. � � � � � WA7ER NEATER � ������ O CU+35� � LI",..ENSEO CONiRACTOR$DECIARATION � D�STRiCT NO, vROCE55F0 BY � I heroDy affirm thof I om licenssd under provlcions of Chap�sr 9 GASSvSiEM � OUiLEiS- ��� (commsndng wi�h SecNon 7000)of Division 3 of�he Business OUTlEiSOVER - ���� p�,� ond Profeuions Cods,aed my litenw ia in fuq forc��yood eff«L � 5 vER SvSTEna -� FDIAN EL �, VAII�ATION . �� license Number (7'�`��� lic.da� `� �/�/� �j FINAI �ff i O ` Conhatiw � � •Dala� BY //f�`� W '., ❑ al 1 om exempt undsr Sea y... B.BP.C.for rhis�eason , , 2 " Plan check fee � . ���� � . PLUMBING PERMIT ISSUING FEE S Q � ; Siprwl�re i . TOTAI fEE . �� � 0.S A . . .- ; Plao chxk opplicoat � . �• e a . •5 �I, SINGLE fAMILY - HOME OWNER•BUILOER DEQARATION Nome� � . . .I � +v II,S O - I hereby offirm�hat I om�Kempt from�hs CoMracbr's Lk�nte . A���u � � • +G r,5 Q�- . _ , ��for�rhs followiny rea�on(Seerion 703L5,Boslns�e and - � � � - � ' j •�euions Cod�): City isl.No. 0 ft 2 7�8 7 �� 1,as own�r of ihe properly,.will do ths work ond Ihe . ► sfructure is not Inlendld or offered ior wla(Settion .. . .. . . . . . . . ._ . . 7041,Business and Wofeaio�s Codo). . � . CONSTRUCTION LENDING AGENCY � � � �� � - - � :�' - � ��� - � ' I hs.eby aHi.m rMt rhe.s is o constrvcrion I�ndinp cp�ncy for fhe performanu of ths work for whkh�his permi�fs issued � � � � - � � - � (Sec.3097,Civ.C.). .. � - . ;' Lender's Nome � - � Lender's Addraa � . . � . . . . . . , I cenify fhar I Fwve reod ihia applicotion ond state tM1a�the . . .. . . . . .� . . . _ I obo�e infamo+'�on is eorroet.1 apree ro eomply with ali Counry � _ � ► I ordinoneea and Stols laws roquloti�p Plumbinq,ond hereby oo�hor�zs ropresenro�ive�of rh�s Counry�o enter upon�be � � - � � ' - � � i above•men�ioned popeny for inspxtion purpo�e�. — SEE R6VERSfl FOR EXPIANATORY IANGUAGE ' 8 a7�{7 ' Sipna ure of Permittes Dars ' � I , �. , . , _ ; : : � _ _f _ --:�-- , �. (.. . •�: - J J� .. __ . . _ .',-..... - . . . ._ � , ...�:c... � . . _ .�..... ..... ........ ..,.... ,T... , . . � , ,.,.....i ..... .. � ., .: ,..._: li�, ..... . , .. �.. . . .. �:� t. . . . . . . . .. I . . .. _. 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