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HomeMy WebLinkAbout1614A `"°R�ERS•�°"'PE"SAt'°"°EE�ARAT'°" ` APPLICATION FOR PLUMBING PERMIT I hereby pffirm that I hove a certrfcate of wnsenf.to self 76A6b7A - � � � insure,or a certifimte of Workers'Compensaiion Insuronte,-. ,CE elz{REU.-t0/8F) - ----� --- - �- . � � � �. � � or a ce�tified copy 9hareof(Sea 38W,�ab.C.}... COUN7Y QR LOS AMGELES BUILDING ANDSAFETY_ Paolicy No. 60&4266 comPa„y Gr. Amer'lcan e�„�u� �Cert f�ed mpy��s here6y iurnished � - - � � FOR APPLICANT TO FlLL IN(PRINT OR TYPEI �BUILDING - �Certif ed�-mpy'rs f led w.ith the munty:buJding_insper- - - �----- ------ ADk3RE5S - tio.ndepartment. . � . � NUMBER FIX7UREONITEM �Q .FEE , -� � ---- �� LOCALITY : . - h�af�3-$� -� APAlicanf L23V2YtOY1 � � . :WAiERCLDSET�.. ::._. .. ._-- t� -- °'� � NEAREST. .� .a . ' . h � - - CERTfFICA7E OP EXEMPFION FROM:WORKERS' --� � BATH TUB ' --"' GROSS ST. - _ . � . .....__ _.__ : . - COMPENSATION INSURANCE -. - � OWNER- - - �This-section ne,ed nof 6e comple#ed if the work involved 6y . SHoweR- � � � POrid2YOSd. HOIDES �'I fhe-permlt is forona hundred:dplla�s($lOUj or less.)� � LAVA70RV . � � ' +�,���-- A DRESS � ' . 1 certify fhat im the�performance of ihe work for which rhis . � . . � _ � � � -� � - permit is ssaed,I shall nbt eniploy any person m a�y-manner � SINK � e ��. � CITY ._. ,,., TEL NO. . - �.� ' �so-as�io become sub�eci to ihe Workers'Gompensation Lows. DISHWASHER � � ' ' � ' : coNrencroe Leaverton ��os. , Snc. �. Date �- - Applicdni - �CLOTHES WASHER � qpDRE55 � N�'TICE-TO APPLICANT• If, after m�king th s Cert'fwqte of - _ _ _ �.�721 H']�:2 _ _ -� f otion, u.-5hvutd bemme subl�ct"-lo ihe Woekers' `SiNIMbi[NGPOOLREcePigR-� _ `�� :� � - -�- -- _ ---_ .. " -. �- -- � .. C.. .pensotion provisian5 of.fhe-Lp6or--COde,yDu-mus{{offh- . �qWN�SPRINKLER SVSTF,M� CITY , �iri TEL NO. _ with-cbmply.wi[h such-provisions.or�Jkis.permit shall b2 STATE � � LIC. � ' deemed ravoked.- �'. � � . Wq7ER HEATER- � LICENSE NO. "" -'' �LRSS � �LICENSED CONTRACTORS�ECLARATION- �: / - - ,,. � �DISTRICT NO. . �PROCESSED eY � GAS SYSiEM OUTLFTS {'� y�y �� I here6y aff rrn ihoi I am licenged under provisions-of Chapier 9 / � � l� �!L'� '"� trX-..•�i' - ,(rommencing wiih SeUion 7000)of pivision 3 of-the Business OUTLETSOVER - , . �, and Professions Code,and my license is imfull farce ond effect - �5 PER SYSTEM ,.., � 191959 __> (� ,.,.-- oArE� � � �,�! VALIDATION � License Number Lic.Class C36 , - - �� Leaverton` 2-13-84 F�NA�C�7� �'� � . - Confrador� - Ddte- . ._ 8Y . - p- ' ❑ �I�om exempf under�5ec.- . .-. . . . . . .. . .. .. . .. . . �� � . B.&P:C.for thls.reason . . . � : . . � � ► . - . .. � . „�'�'_, Plan check fee, °, � � � -- Dafe: pLUMBING PERMIT ISSUING FEE$ � - - - . �Y� Signature . . . �- . . �L ��t . .. � � � . . .. . . � � - TOTAL FEE �,(�,I�7 �s . - ' � ���I G���.�1 A �. . ... ' - . � . � � Plan check,applicant � � � � � . � ,, q. . � . .- . � � SINGLE.FRMIIY � - � � - . fir " ��°�` "� � ; HOME OWNER-BUILDER DECLRRATION Name - - __ ._ �� _ - I' =6y affirm thaf I om exempt:from the Cg i ac+or's License �Address - - � -`�� - ' -- - -� � ��z$�`t L ;or the followfng reason (Sat�on 7031 5, 8usiness and - _ Protessions CodeJ;- � � - � C ty � � Tel.No, � . . � - . �`�� ��''b"'-�✓� 3. � I,as owner of ihe property,will do fhB work and ihe _ � � --�- . � �, -� '��,'� i--�/. -„ girudure is noi ni�n8ed or oFfered-for sale-(Section - � - __ ..�7044,Business and.ProfessiongCode). � � � � � - -- -- � . � f��' � CONSiRUCTION LEN�ING AGENCY � � . � � � � - - � ._ -.- ,";. . I hereby nffirm thatihera isa consfruction lending�agency far - - . � . � � � �the performance of the work for which��his permit is issued . - � , � . � . � . . . . . . � (Sec 3097,�Civ.'C). . � ... . . , .. � . . � . � . tender's Name . . . � � � � � . . ... . .. � � Lender's.Addiess- � . . � . . � . . . � -���� � - .. -I�cettify ihai I hdJe read this application and state thai ihe , � � . � - - above informatipn-is corred.I agree to comply with all Counfy - � � ord�inances and-State laws'regulating Plumbing,and hareby . � � . � - �� ��� o�thori repre ntahves of this Couniy ro�enter upon the - . . � � . ��-� � . � - ��� a e nenho �,�'uroperty for insp-ction purposes. ��' f' �. �. ;�'r ��,9�p �� �J��g -SEE REVERSE FOR EXPLANATORY LANGUAGE -� _ . , f �,�• � '' '� Signature of Perminee - � � �Date- � � " - � . - � - -- - - - 'µ �`. _ _ 3 .,�. _ ,_.- .4,��� z ...-.- �. �._ ,�_ � _.."E o._ . �,.,, ..... ,.� -,�..,. .. ... -. - _ .,. .., _...�—.:_�� ,:-,: ... ..�. .�_:' .s , s�� _ :�.�.. ..-- . _ . .- _�.�.�.>.a s .��'Y_,.,�_� _ '" �.a , :: � . -, 1, �� -� � �,s � oszs 1 .- � � C � �,:, � � . . . . . .. . . _ . . � � �� � a 2N � L 6.5. _ . . . 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