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HomeMy WebLinkAbout0910A (4) � . ,"!WORKERS'COMPENSATIONDECLARATION - �p.pppbDPW�ti87 - APP�ICAIION FOR PLU�BING PERMIT + I Fje e�y,�pffirm that I have a cerfifimte o(consent to self in- �aA��A , , . , n ��� ' sure ora certificote of Workers'Compensation Insurvnce,oro 'CE eD�REV.9/B6� � � � - � � : � � � �� �" ' � cert fied copy thereof(Sec.3800,Lab.C.� ��. . . . . . �./ .. CQUNTY OF LOS ANGELES . DEPT.OF PUBUC WOR S '�� �� ..Polity No? .. . .. �- Campany � � � � � � � . . . , . . . . . _ j r� Certified copy is hereby furnishad.��� � .- . � � � O � ' FOR AGPIICAN7 TO fllt IN(FRINT OR TYPE) BU�LDING � - �-_� Certified copy is filad with the couNy building inspeciion , ADDRESS ` depUrtmenf. � '- . NUMBER FIXTURE OR ITEM [s� . FEE . , ��,��,Y D- .,Dafe � � Applimnl� . . . WATER CLOSET(TOREfI NEAREST. , . . CERTIFICATE OF EXEMPTION FRQM WORKERS' BATH TUB � , GROSS 57. ��� , � �� � COMPENSATION INSURANCE � � OwNEa � �� _ � � - -� �� SHOWER � � � � (This fodion n��d not b�camplN�d I#}h�work{nvolv�d 6y Mn4 / p�A . . Ih�pormp is!or on�hundrod dollon(5�00�ef I�s�,) � . � IAVATORY " � ADORE55 p —� U � � I certify that in ihe performance of ihe work for which fhis per• SWK � - � i mil is issued,I shall not employ any person In any monner so � � (ry LITY j 7EL.NO. , � as 10 beGome Subjett lo Ihe Workef5'COmpensO�'on law5. ' DISHWASHER � CONTRACTOR . � Dare�_�;���APPIiConl' CLOTHES WASHER � ' . �`�R�CE APPI CAM:If,o(ter making ihi rtificote � ADDRE55� j 3 " ,.ption,you should bacome sublecr 10 the rkers' pe - SWIMMING POOL RECEPTOR . CITY TEL.NO. salion provisions oi ihe Lobor Code,yov musf(orfhw' co � ' �AWN SPRINKIER SYSTEM' . � ly wilh suth provisians or Ihis permit shall be deem vok- STAiE LIC. � . ed. ,�'� . . �� � . '� ' �. � . WATER HEATER �\ LICENSE NO. CLA55 . � � -��LICENSED CONiRACTORS DECLARATION�. - V u DISTRICT NO� 7ROGESSED BY . . � I hereby affirm Ihat I am licansed under provisions of Chapter GA5 Sr57EM OuilEiS a .. . , 9(commencing with Section 7000)of Division 3 of the Business. � ouiteis ovee . �� +�nd Professions Code,and my license is in full(orce and ef- � 5 PER SYSiEm FINAL � � � ALIDATION 0. ` �AT .✓ O � ..License Number b � Lic.Class�.._ . ., . _ � � V ..L�iJ�C.'-�`A.��L - Date�t._ . _.. . . . BIY A � � � ,- Conrr6ctor _ . . . � I om exempi onder Sec. � . . - .. yVj b : � 6.8P.C.(or ihis ieason Plon check fee � � � �. . ._ _ � . flO1e-�� � PLUMBING PERMIi ISSUING FEE S � —Q � I . � . s�9�ar��e TOTni Fee ' �0 9 1.0 A . � SINGIE FAMILY � . �� - HOME OWNER-BUIIDER DECLARATION � � Plon check opplimnt - �.. . , . #.'� � � � �5 , r,.Lh�re6y affirm Ihat I am ezempt from the Contracfor's License Nome 2 � . ', . � - � . ��• �e�j.b',_5� � for fhe following reason(Section 7031.5,Business and � � � � - .iofessions Code: Address � � � ' � - . � � � ' . . � . . . . •J�n.:�c=i � I,as owner of the property,will do the work ond Ihe Ciry Tel.No. � . 0�,� 6_8� � strucfure is nor intended or offered(or sale(Section 7044, . � � . . . . . , . . , , . ' � ��Bosiness and Professions Cadea. � � . �, . � . � � � � CONSTRUCTION LENDING AGENCY'. � � ' ' � - - - ' � � � � I hereby affirm tha�ihere is o conslruc�ion lending ogency for _ . � _ � . .. . ' � � the parfoimance oi ihe work for which�this permit is issued ' . � � - ' � � '. (Sec.3097,Civ.C.). � . � � _ � �� � . ' Lender's Name � . � .. . _ � . . � . .� � . . � � . . . . . . � Lender'sAddress �� . .. � . . . � � � . � . I certify�that I hove read�his oppl�cotion and sraie ihat the � � � � � � ', , � ��� � �� , above informalion is correcL I agrae to tomply wi�h ali Couny , _� �_ _ , � , � ► . .' ordinonces ond State laws regvlating Plumbing,and hereby . . - � , ' puf ize�epresantatives f Ihis Caunty to nfer upon ihe � . � � � � ab e- en�ioned propart or inspection p I�iose � �� -" � ��- ���� . - � - . �� � - SEE REVERSE FOR EXP4ANATORY LANGUAGE � � na e of Permitt D e . - � - . - - , ; INSPECTop'S NOTES OWNER BUILDER DECLARATIOM APPROVALS OATE INSPEC70R'SSIGNATURE � � � � �� � UNDER SLAO WORK .. . �1 INAby p111f111�ihRl 1 MI exampt lrom Me Contraclor'a � ROIIGH PLUMBING i �a,— . Licenee Law for the foilorlaq reeaon(Section 7031.5, � GAS PIPING -. .-.. . . ... ... ._ . ,_.. .. . . Buslrress and Pro/esslons Cade). Any c1ry or crounry , . . wh/ch r uhes a eq pB�mft to cortsirucL alter, lmprove, cns vetiT � � ' demoflsh or repalr 8ny structura,prior to!ts Issuaace. HOT W ATER HEATER ;� _ . �also requ�res ihe app7lcanHorsuch permit to file a stg�d cwMaw�vixruaes � ' statement thai he Is licensed pursuant ro the provlsions , . . . . ,,._, ' ' - � ......of th6 COAtfBCtOPS 11CBnbe LaW(G78pt8f 8(COl7ilR6DClqg � cas resr ,: ; wlth Section 7000)of Dlvls7on 3 0l the 8uslness and Pro- urain co.NonF+eo - /essfons Code)or that he Is exemAt therefrom anC the . . basls for fhe a!leyetl exemptJon.Any vlolaflon of Secflon FiNai ` �'nla.on��ant- � � 7031•5 by any applkant for a permit subJects the applF cant to a civll penafty of not more than live hundretl '.,'� . . , dollsrs(.Y500).: � INOUSTRtAL � � . . . . . I... • ; .❑i.iA OWIIBf Of 1�18 pI0{IB11y WIII d0 1�10 WOM(,ifW iM ' WASTE APPROVAL � ' � ' � SlNC1UfB 1�110f III�BMIBd Of ON9/6C(O(l8I8. . (Sec.7044,BusYness and Professlons Code:The Contrsc- ` � %. : : ' - ,, ror'sLlcenseLawdaesrmtapplYtoanownero(pro^���-= _; _ . ' ' whoDWldsorlmprovesthereon.andwhodoessucr. k . . .. . , _ - - hlmself provided that such lmprovemenis are not lntentl- - - � ed or oNered for sale.H.however,the buflding or,lm- ----- �.� `'' ` ' provement Is sold wlthln one year of complet�on, the ` owner•bullder will have the burtlen of proviog that he dk nof bulW or improve►or the purpose o(sale.) .. , 1 am exempt under Sec: � - '- _ ,-B&.P.C.tor this reason _ .-.. . . _ oats _ _ _ ; _ : , _. owner INSPECTOR'S NOTES _ - � -� _4 i . ,. .. : �� '; � � � � .. ' , ., . ,.-' ..:.'. .�. _ i-...._ , i . .. � .. . . ' . - ' . t : � . . . . . . . . � . .� . . � .,._ ,...., . . ., . . � . . . : .._... ... .. . ... ��,.. . I ..