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HomeMy WebLinkAbout1800A (10) i.. __.-----______----__._..__..__ . . ...._._. _.__ _, . . ._ . . . .. ._ _ _ __ _,�- ____ --- �. WORKERS'COMPENSATIONDECLARATION ��ews�v� - � APPLICATION FOR PLUMBING PERMIT � I hereb affirm that I have e certificate of consent to seI( cE�n zeo � � insure,or a certificate o[Worken'Compensation[nsurence,or , ' �. �—".�� � - ' . a cartitied copy thereof(Sec.3800,Lab.CJ � Policy N�"�db�`�SCompanyT"����4^�*M�4rr COUNTY OF lOS ANGELE$ BUILDING AND SAFETY I � Certified copy is hereby turnished. FOR APPLICANT TO FILL IN(PRINT.OR TYPE) BVILDINa g51 GREAT BEND DR. � ' ADDHESS � CertiCed copy is filed with ihe county buildiny inspection NUMBEq FIXTUqE OR ITEM' • FEE �i depertmen � LOCAUTV I ate�Applic �����-.^ S�� N'ATERCLOSET ' NEAR ST , ---.� � BATHTUe . CROSSST. CL•RTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATIONINSURANCE � SHOWEF � -. OWNER � � � MAIL (This SeCtlort need not be CAmplCted if the work invOlved LAVATORV ADDRESS � by the permit is tor one hundred dollaza(5100)or leu.) SINK � c�Tv DIAMOND BAR TE�."0594-513 � � I certify that ia the performence of the work for which thts , DISHWASHER '� � � permit is issued,I shall not employ any person In eny manner � CONTRACTO p �� so as to become sub)ect to the Workers'Compensstion Laws. CLOTHES WASHER ��� � F' ADDRESS'214SO GOLDEN SPRINGS DR c� Dete � Appticant � W � SWIMMING POOL RECEPTOR . nD d � NOTICE TO APPLICANT:if,after making this CerHCcate of CITV TEL.NOS9S JS�I N � Exemption, you should become-subject to the Wbrkers' � � LAWN SPRINKLER SYSTEM STATE � LIC. � �, Compensotion provisions of the Labor Code,you must forth• � �ICENSE NO. ClASS with compiy with such provislons or this permit shalt he WATER HEATER . - � � deamed revoked. � GAS SVSTEM OU7LET5 � DtSTRICT NO. Pq0 SSED BV E � LICENSED CONTRACTORS DECLARATION . Ou7LETS OVER �� � O� IO �tir-t�/ �. I hereby affirm thot I sm licenxed under provisions of Chapter � B PE R SYSTEM � 9(commencing with Secdon 7000)of Division 3 0(the Busi- ' - � • FINAL � ness and Professions Code,and my license is in tuli torce and �`*-P +�-� �UC� DATE VALIDATION � effect. � - tt � ���,,�� FiNAI. � � License Number.ZL_!�_ Lia Claas S3 . gy ��� r � 1 , � Contractor�sti�v�"[a��SDate�—aa�� � . �j � � . �� � I am exempt trom the licensing requirements as 1 am a ' P�en ChBCk fee � � � . licensed architect or a registered P�ofesaional engincer pLUMBING PERMIT ISSUING FEE E �J(f . � �- acNng in my profeaaional capecity (Section 7051. Bus• � � ' iness and Protessions Code). � 70TAL FEE � �i O(f , Lic.ot Reg.No. Date Plan check applicant . �. HOME OWNER•BIfiLDER DECLARATION Nam� p OLS CO � � � - . I hereby affirm that I am exempt from the ContractoPs Addrasc ' � � � � License Law tor the foilowing reason(Section.7031.5,Busi• ' Ciry . Tal.No. � � - ness nnd Professions Code): � ' �� � /,as owner of the property,nm exclusively contncting - - � . �� with licensed contractors to construct the project - (Section 7044,Business end Professions Code). , . � ' . . � CONSTRUCTION LENDINC AGCNCY � '. � . . . � I hereby aftirm thet there is a construction lending agency ' � , for�ihe performence of the work for which this Oermit is �. - r�� S O,O A �� lssued(Sec.3097,Civ.CJ. , � -� � '� - ' �. Lender's Name � � � - . , t:. . . . .5 � Lender's Address , - � � • • � 6�� �� I certify that 1 have read this application end state that the � � � '� above informetion is correct.1 aQrae to complY wilh all County � SEE REV ERSE FOR F.XPLANATORY LANGUAGE ' ' • � �C�" � ' ordinances and State ]aws regulaHng Nlumhing, and hereby � . ' authorize rep�esen[ativea oC this County to enter upon the , b 7.'�J—8� � nbove-mentioned property for inspecfion purposes. � � - � -� �- �� _ 7�-�O ' � �gnature of ee—� Date _ . ' � . APPqOVALS �w�onTE irvsr-ecrorzssicvarune "�NSaECTOa'S NOTes�� ' � -� -: �� . 01�'A'ER-BUILDER DECLARATIO:v . � UNOER SLf16 WORK ' '�- '— � � - �'�' " �' ' '' � F{OUGH PLURIRING �hC�ee�}':a(��RI tlt�t-t-am e�Cln�t,`IRfn(heC[mtr3CtOr5 ''��-'�License��La�r'ftir thC�tolla�r•in reason�fSeciion 703I.5, GASPIPING......... . ._.. . ., . ._,... .... . .. ... . . ... . ..,. . ... . . . . .. .. ... . . � S � � '� "" Be�riners and lroJrssions Code/: .fny, rrty or count�� GnSVENT .' '?��-�-�.:':�.�`%�.: ., =c' � � �... .. � �. .. � : . _ ' - whicH requires a pe�urir to�construct, alter, i�npro��e. . HOTVJATER HCATER .,,�. � � � � � �dernolish,or rep,�ir any strucfure,prior to its issuance, � . a7.ro requires t1�e opplicnnt�fn� such pernrit to frle�a �'�Uv�in7cFl�c�uFteS�-- - -1 � .. ' ' � -'-" � �� � ._. .sigited�statement ihet�l�e�is Ircensed.piirrtiant to dic cas:resT �'���;) �-- ��� � � � � �� � p.ovirionr-oJ tlie Contracror's Liceirse Laiv IChaprer 9 �� � ��" � ��� " � -'� �' � (commefrcirrg x�iNr Section 7000J of Dirisio�i 3 of the � UTILf7Y CO.NOTIFIED ._ �.,„,�._,. " , . . ---_- _- - -_:-_. _ .- . .... . . Busi�resa�'and-F'rofcsfions'CodeJ or rlmt Ire is exempt � . ,-� _.. . _. _ _ _.._ .. ._ . _ . _ .. . - . . � - , .^ � � ` - . - theref�om and tlte baais jor tl�e alleged esemp�iort.A�ry � �INAL _.. . : . ... . _ . . . ' . � . - i:���•rf-�3art1- .. . ' . . ....: ..- . ..'..-�. ��, . ��iolation of Sectia�7031.5 bl'a�rJ'applicout jor a perryrit —:'��l'-"-`,,-�.. . � - „t.' �subjecfs the applicaru to a ci��i!penalty of nw mo�e lfimr irvousT�i�ai � — _ �r .. . . .. . . �. -, , � : .ji��ehu�idre�/dolla�r(5500/.: � � � � � v�q re aFaHova��`�'�' 7� n . '�,rt;�i 1 � - - . . � ❑�I,as o���nct ot thc propert5'«�ll do tlie i��ock,and r. .��..�,..�....., ��,,... ...,�,.��,.. � ' ��. �._ . � . �� ��tls structure is not intended or of(ered for salc. � . . ,.._,..T �"T �� � : , � : �` � ,.-•�" . � . ......... .. .. _... ... � .. (Sec. iO4�t. IIusinesr arrd Aofessior.s Code: The Con- ' �..,- ` . �-,.; ;..-. .. . .,_� _,..... � �. .� '•._ . . . . .- . �. :-, � . . ' . ..tractor's License Law�does not opp7y�to mr-ow�ner oI -> .. .-.• . ._ ... ..... ... ...�.' :- - . �-� . . , . .. .. propeny.irho Guildr or imprm�es rfrereon,and wHo does � ��' :.;��:; �r n c�r r , � , � �� �� � -� �� ��-- ��� --.- �- � - -. rudt work�hiiruelf yrovided rhat sudt bnpravemcntr � ..._ . .._-.�, .,,:.-.�...,.. ... .._�" , .. '._ ���� ... �. � � � ����'� mc r.or iute�rded or oJjered for sa(e. If�.howevcr.�d�e � .. ...i:�.-. . . .. -. - . � . � - . , -• � _ . building or improvemen! 7s sold within one year�of . , ', ., ._ completion,� �he ownervbe�ilder wi!! Prare !he burden '_._._ �.�..�..'._'.. �:�._....-.�_. ..__. _ .� _.__.. � . . . � ' � � oJ Aroring thnt !re did no� build or improre.jor.the - . . _ . . . . .. . ... . �. _. . � . . purpose of sale.) . . .. � , ..,.:,��� ._`,�;� , . ' . ..., •. ' � . ' � _ . � 1 am exempt under Sec. i _ _ _. _ . _ _ _ . . � _ B f P.C:for this reason ' _ .. _. _ _. . -_ . , . _ , . , ,�, ___ . _ _ _ _ , . _ Date _ O�cner � " INSPECTOR'S NOTES . "�`�"� � ... .. "':Tl�'.:' � � . � . . . . . . _ .r'ry .� 'r'' , . � , � . ...... , �. .. � . . , , . .