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HomeMy WebLinkAbout0846A woRKERs•coMPeNsarioNoeanRarioN APPLICATION FOR PLUMBING PERMIT � a I here6y aFfirm ihot I have a certificate of mnsent to self 76A667A � insure, or q certifimfe of Workers'Compensafion Insurance, CE 8U(REV.70/BI) o�o ce�t�t�ed o�y rhereof(Sec. 3800, _b.Ct). � COUNTY OF LOS ANGELES BUILDING AND SAPETY P❑ol�icy No�_.�.J °t;ompany ' �'� . Ceriified mpy is hereby fumishe . Fph APPUCANT TO FILL IN(PRINT OR iYPE) bUIIDING • � Certified copy is flled with the co�nty building inspec- P.DDRE55 —� � tion department. NUMBER FIXTURE OR ITEM �' FEE � LOCALITV[� WATER CLOSET /} �'---�i Date Applicanl ___. �`Q NEAREST CERTlFlCATE OF EXEMPTION FROM WORKERS' BA7H 7UB /�h CNOSS ST. - COMPENSATION INSURANCE -- � �f OWNER ° SHOwER �O .. (This section need not 6e completed if the work involved by ��,,� � the permit is lor one hundred dollars(S10Q)or less.) LqVAtORv AD�Re55 � _— . i I certi4y that in the performonce of Ihe work for which this � permit is issued,1 shall not employ any person in�ny monne� SINK � CITY "�. 7F.L NO. so as to become subject to the Workers'Compensotion Laws. DISHWASHER � COMRACTOR Dafe Applicpnt CLOTHES WASHER ADDRE55 NOTICE 70 APPLICANT: If, after makEng ihis Certificate of �.� c�,� • Ezemption, you should 6ecome subject ro the Workers� SWIMMINGPCOLRECEPTOR CITY TEL.NO.�� Compensatlan provisions of the tabor Code,you must forth- �nwN SVRiNK�ea SYStenn with comply wifh such provisions or this permit sholl be STATE LIC. deemed revoked. WATER NEATER LICENSE NO. CLA55 � LICENSED CONTRACTORS DECIARATiON DISTRIQ NO. ��PROCES55$EEED BY I hereby affirm thar I am licensed under provisione of Chapter 9 GAS SVSie1�n Ouite75 � ��..�/ /�. (commencing wifh Section 7000)of Division 3 of the Business pUTlf.TSOVFR and Professions Code,and my license is in foll fo:ce and effed. 5 PER SVSTEM i _ p�ryAL ` ^ �_g�� VALIDATION a } G �� DATE , �� License Number S����� Lic Class � o FlNAL O, Contronor�iL�1J42�—Date ������7 — 6Y O � ❑ I am exempt under Sec . � � B.BP.C.for this reason ► . � ; Plan check fee �08G,6A n' � ���e� PLUMBING PERMIT ISSUING FEE ,S � � Signature $ �� �� - '�•• e m •5 Z{ TOTAI FEE �;1 7 Plon check applicant � � o ♦QO,J�� SWGLE PAMILY � � NOME OWNER-BUILDER DECIARATION Nome m ' `�'��J��-' � 1 hereb offirm that I am exem t from the CoMracior's License � Law for the following reason(Section 7031.5, Business and Address � . �„_ u�,� L�—�v 7 -� f Professions Code): Ci�y Tel.No. � ❑ I, as owner of the property, will dv ihe work and the - . i slrocture is not intended or offered fo�sale (Section , � 7Q44,6usines=_and Professions Code). CONSTRUCTION LENDWG AGENCY � I hereby affirm thai ihere is a consfruction Iending agency for ihe performance of ihe work for which this permit is issued E (Sec.3097,Civ.C.}. � Lender's Name -� i Lender's Address �. I certify tha�I have read this appli<nfion ond sta+e that ihe � � a6ove informotion is mrred.I agree fo mmply with all County �. ordinonces and State laws reg�lating Plumbing,ond hereby � . outhorim representolives of this County to ente! upon �he above-m on p� e.�y for Inspec�ion purposes- - SEE REVERSE FOR EXPLANATORY LANGUAGE �-\�-� . Signature of Permiuee Date . v� u o o�� � � � � d � ` � � � N N ry � C L �, � .�� G `� O- -a O O ,. � 0 �, p� ;t� � p.'9 ,G O V V, 7 ��•- ,.-. S .. G_ 4� .L s, O-fl G) 4 7 �O C) C'ro �.9 Q Cn p� . , r . v n �,�� Q ✓, G�L ? �L 0 p � G O > � 'V� , i=Q D � C ,'�� O N � I, a� C�£j} � �O . O C C . �- .' p Q�G `G T�� �"°` �' O O O ��C � ..O-V O C Q N O N , G O p cw L p O � N p O S S % �U 6 � £ O T N n" . . . 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