HomeMy WebLinkAbout1691A WORKERS'COMPENSATIONDECLARATION 7{A��]A APPLIGATION FOR PLUMBING PERMIT y�
� [ here6y affirm that I have a certiCcate of consent to seif cc en�z-�o)
, insure,or a certilicate of Workers'Compensation Insucance,or . � � "'�— . . I I
: n certified copy thereot(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUI LpING AND SAFETY �J
Poticy No. Company
�� � Certlfied copy is hereby fumished. FOR APPLICANT TO FILL IN(PRINT.OR TYPE) � BUILDING-- '
❑ NUM6ER FIXTURE OR ITEM • FEE ADDRESS .
Certified copy ie filed with the county building inspection
� LOCAIITY
�i Aepartment. WATER CLOSET
, Dete Applicent NEAREST � �
�, � � BATHTUB �. CROSSST. ✓�.
� CERTIFICATG OF EXEMPTION FROM WORKF.RS'
COMPENSATIONINSURANCE SHOWER � � OWNER ��
' LAVATORY MAIL . }
' (This section need not be eompleted if the Wotk fnvolved ADDRESS f+�G� �-
��� by the permit is for one hundrcd dollars(St00)or lese.) SINK �
� . CITY TEL.NO. U
I cer�ify that in the performence oC the work for which this OISHWASHER � `� , 0
permit is tssued,I shall not employ any person in any manner CONTFACTOR �
; so as toi beco��y(��subject to the ' ker'C mpe�nsJatJ"rn'/ey�',s. CLOTHES WASHER ADDRESS � �'U . W
� Date ?���"— Applicant - � "" ""�� SWIMMiNGPOOLRECEPTOR � O.
i NOTICE TO APPLICANT;If,after making thi 'er[ificate of CITY � ,�}g'�� TEL.NOf`C(�'ar,s' tn
i Lxemption, you should become subject to the Workers' LAWNSPRINKLERSYS7EM � ?
STATE 9 / LIC. p
. Compensation provisions of the Labor Code,you must torth- � UCENSE NO. •�`g�� CLASS !!
� with comply wi[h such provisions or this permit shati be WATER HEATER
-deemed revoked. GAS SYSTEM ,1i OUTLETS � � DISTRICT NO. PROC�$SED BV
'� � LICENSED CONTRACTORS DECLARATION OUTLETS OVEH O �J(c.u-[�
�, I hereby affirm that 1 am licensed under provisions ot Chapter 6 PER SYSTEM
� 9 (commencing with Section 7000)of Division 3 of the Busi- . FINAL[� VALIDATION
� ness and Professions CoJe,and my license 1s in ful!force and DATE.7 �dJj,/
eftect. /'
M License Numl er��/� Lic Class �p• � ev AL J
LA ��l G2 � l.l.�%i r�
^oMra:tor���� '� Date .
'� I am exemp[ from the Iicensing requirements as I am a Plan cheek fee � � -
.11iCensed architec[ Or e Teg�stered professional engirteer pLUMeING PERMIT ISSUING FEE S ' ,�'(J
�acting [n my professionai capacity (Section 7051.Bus•
�iness and Professions Code). TOTAI FEE � S�f �
,- Lic.or Reg.No. Date Plan check epplicant � -
� HOME OWNER-BUILDER DECLARATION Nem• �� . -
', 1 hereby effirm that 1 am exempt from the Contractor's Addrass . �
! License Law toi the following reason(Section.703L5, Busi- ��iy Tel.No. �� � � � � � � -�� 6 9,� A
. ness and Professions Code): � �
�� � 1,as owner of�he property,am ezclusively contmcting � � � �. � �� �'� � � � �5 .
wilh licensed contractors to [onstmct the project , .
� (Section 7044,Business and Professions Code). � . . . - .. .��-• •1 2 5 D -
CONSTRUCTION LENDING AGENCY � . . ',� �� 2 S O u ,
� 1 hereby nffirm thet there is a construction lending ngency � O�O� �H�Z
for the performance of the work for which this permit is � _ . . .
• issued(Sec.3097,Civ.C.).
j Lender's Name � . � . .
� Lender's Addross � , .
� I certify thal I have read this epplication und state that the �. �
� above information is correct.I agree to comO�Y with all Cou�ty . . SEE REVERSE f�OR E%PLANATORI'LANCUACE .
� ordinances and State laws regulnling Nlumbing, and hereby �.
authorize reprosentatives of this County to enter upon the . , . . ,
1 abo�ntio �rty tor sp n purposes. � � -
r
�.✓�- 3-I-�'z-
Signa[ure of Yermitt� Date ' - - '
S
APPROVALS � DATE INSPECTOq551GNqTURE ' " �NSPECrOR'S T�DTES� ' ' �� .OSti�NFI?-BUILDER DLCLARATION , �
UNDER SLA6 WOflK -� . � . .. � ' ' �� � .
. . .. _ . , . , . . � .. .
� • �- � -�� l he�chy affirm that 1 am esempt from Ilie Contractuc s
ROUGH PLUMBING - -Liceme Lsw for tlu-fo!Iowin�mnson�Secfion 7031.3.
GAS P�viNG .: ... - �(P } � . . •........ . .. -:- .. . . ...._. . .�. .- piuLicrs ar�d Pro esr'ons Code
f )' .Lq� cit�� o� rounq� .
GASveN7 - �, ... . � . �.'�.� . � � � � �� �. �� . . -. �.�Iricp rcquires c prr��iit ro constnict, altcr, irnProrc;
HOT WATER HEATER � , dC111o1(SF:,DI ifpcir any.rm+cd+re,prior to its iss�mrt;c.
PLUMBING FIXTURES - � � . 0150 If(juirCs t11C aypliCartf fnI StlCl+ /1CT11lit fD fi7e C
� si;�ucd smtenient rhat_he is licenred p�usum�r ta tlic
' GnS�7E57 ��'�•�� � � � ,� �fCi[luv—'- � � � � � pro��isiar.r oj tlic Conrractor's Liccntc l.an�(Cl�apter 9
UTI�I7V CO.NOTIFIEp � . � (rattntcrtcing�r.ifA�SeCtinn 700QJ of Dirisiort 3 of tGe
� _ . . . . ., ._ . .� . . . ' . . ' Gutinesc and ('rofes.tiacs CoAeJ or �hat Nc ir e.rern�t
' FINAL . ���,lj, pH, G�Za�;( ��:�• _ - _ ' therefrorn a�i;t IF:e b�ris for tl�e allegcd rxemplion.:lr{v
. . .. . .. . - . .. . riolation of Scetirin iQ3L5 hy any applicanr fara yern�ir
. . . . �,nibjdcts 7Lr applirarr(ro n ciri!pe��u7ry oji+ot rxnrc tlmn
� INDUSTaIAL � . , .. .. .. ' ' ' � .fi�•.".h:lndrCddo114rs($$�OJ.: .
WASTE APPROVAL '� ��� � � �� . . . ❑1,as'owncr Uf tl:c property u�i0 do thc�cork,and
. . - . � ' . ��.thc stcucture is not ir�LnSed or oftcmd for s�lc:•��
- . . _.. . ., . 7 , .... ..,.: . ...:� . . � `,:_ ,��!,Sec:'i0'4,.Dusinesr'en;!Professia�s Codri.-�Thr Con�
. - . - � _ � � ; � � � � '� � trcc�r r's-Limnsc Lc�c dnzt rrot appl}� m�an oxrtcr oJ
. . .-. � . . . . " - � ��propertr.irl:o Gui1Js a�improres tAcrcurr.ai�d x•ho docs
. - . . .. .. . ' . . . .� ' . . .. . . . aitcl: �vor! l;nnsclf prm�idtd Ntat such irtiPro��crnentt
. .- .. . .. . . . .. . .. - . .. . are.ioot inter:drd or�lfcrcd for aalr. If. !�o}rercr. tHe
I . . -. . �- .. . �� . . " b�dldirt;? nr irrrprnrc+ncnt is sold �vithin o�te t'ear of
. . , ., ..1. � _ .. . . complcrinn. t/:e o���r.rr�builder ivrll i;arc Jfic burden
-- -�� '�'��" -� ��� - - �- � � � . oj prorrrrg �hor he did not bnifd or impro�'e for the
purpnseolsalc.J ,
- i am cxempt u:ider Scc. ,
B Ic P.C.for this rcastiu �
, , .
_. ..�
ll�tc '
.. O�cncr
� INSPECTOR'S NOTES � �
+��'� � ... . . _ . . . . . . �� � , . . � . . , . . , . . -
�. � . .. . .. ,. . .. . . . � . . .
Q'C f ., I - . � . . , . ...
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