HomeMy WebLinkAbout0838A (4) ` w"K"r:Ks��°"'PENSAT'°"DE`LAR,�T'°� "A68>" APPLICATION FOR PLUMBING PERMIT �
� I hereby affirm that I have a'ccrtificate of coneept to aelf cE ev(z-eo�
insure,or a rertificate of Workers'Compensation Insurance,or �
'- a cernfie copy thereof(Sec.3800,Lab.C.)
; ,�� ,(�,���- COUNTY OF LOS ANGELE3 BUILDtNG AND SAFETY
� YolicY Noaf�(Cumpany—=(�J� _ _5 . ' / i� ,� �.J
� ' Y�-
e � Certified cupy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TVPE) BUILDING
B �Certified copy is filed with ttie county building inspection NUMBER FIXTUFiE OR ITEM • FEE AD�RESS 2 j 7��,�J�f/¢j���t�'
�3/e�pxri�m[a��rt�.i� WATER CLQSET D� LOCALITV
� Date�Y"��"`APPlicunt�� � �-�— NEAREST c 1
° BATH TU8 CROSSST. � '.'�", '�5'�"�: ''
t CERTIFICATE OF EXEMYTION FROM WORKERS' '� ` . �
� COMPEN5A"I'lON INSURANCE SHOWER OWNER �� �
LAVATCRV MAII 3a - 8� � iJ N s,G`!
1 (This section need not be comple[eci if the work involved �',0 qooRess
7; by the pennit is for one hundted dol(azs (5100) or lessJ i ` �
N ____ I SINK ; � (r') CITY� ����..-__—_TEL. '�..� '• 6 �
I certify that in the performance of the work for which this f �ISHWASHER �
� permit u isxued,I shall not emploY any person in any manner �� OQ CONTRACTOft �vM�/��
_.-_.
� 6o as to beCome Subjert to the Workeis'Compensation Lnws. CLOTHES WASHER I `�
, __ G ADDRESS O
� Date Applicant_ .._ __.. .__.._—..— I __ � � CJ
SWIMMING POOL RECEPTOR i
NOTTCE TO APPLICANT� [f,after making this Certificuke nf CITY �f�� Q� TEL.NO3'Ss� �
Exemption, you should become sub,jec[ [o the Workers' LAWNSPftINKLER5Y5TEM STATE LIC. A �
Compensation provisions of the Labor Cude,you must forth- n NrqTEft HEATER LICENSE NO. � � CLASSL",�j� �
with comply �vith sucL provisions or this permit shall be L-. i ' �
decmed revoked. GAS SYSTEM OUT�ETS �', DISTRICT NO. PROCESSED BY
LICENSED CONTRACTORS llECLARATION - OUTLETS OVER ,�� `� !;r,�,�..t_,� -
1 hereby affirm that I am ticensed under provisions of Chzpter 5 PER SYSTEM ��� " �
9 (commencing with Seciion 7000)of Division 3 of the Rusi- �f FINAL /f
ness and Professionx Uode,and my license is in full force and � . Y'F . DATE ,��1�'y_�„ VALIDATIOI�1
ePfect.
� � �8
LicenseNumber / Lic.Gass�_ PWAL
y/ BV �.-,�Q�lh,y�iitl�
Contractoc}+� Dnte�L}J O/ _ -- �,�
� I am exempt from the licensing requirements as I am a Plan check fee J
licensed azchitect or a registered protbssional engineer pLUMBING PERMIT ISSUtNG FEE 3
acting in my professional cayacity (Sectiun 7057, Bus-
in�s and Professions Code). TOTAL FEE
I.ir..ur Reg.Nu. Date Pian check applicanT
i HOl�1�OR'NER-BUILDER DECLARATION Name �C,�J��
i
� aad�ess
I hereby aftirm that [ am exempt from the Contractor's �.�e a e • o S
l,.icense Law fo[the�following reason (Section 7031.5,Busl- ��ty Tel.No.
ness and Pro£essions Code): 1_• 1 .' �rJ G
� I,as owner of the property,am exclusively co�tracting
with licensed contractors to construct the project o��y �� �� L�,�J�
(Section 7044,Business and Professions Code).
� �.�Q��7
CONSTRUCT[ON LENDING AGENCY . .
i hereby affirrn that there is a constructiori lending agency
for the performance of the work for which this permit is
�iss�zd(Scc.3097,Civ.C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
� above inforntation is correct.I agree to camply with all County SEF.REVERSE ROR H,XPLANA'fORY LANGUAGL:
ordinaitces and S[ate laws regulating Plumbing, and hereby
auth rize representatives of this County to cnter upon the
ab -menti ed p operty'for inspection purposes.
t re o miCtee Date
/
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