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HomeMy WebLinkAbout0777A (4) I hecebWORBmRSh tOl�ha esa�e°f�Dte ot'Rconse°Nto se3f �ce a;;",z_Ba, APPLICATION FOR PLUMBING PERMIT insure,or a certificate of Workers'Compensation Insurance,or , , � a certified copy thereof(Sec.3500,Lab.C.) COUNTY OF LOS ANGELES BUILDfNG AND SAFETY Policy No. Company I � Certified copy is hereby furnished. FOR APPLICANT TO FfLL IN(PRtNT OR TYPE) BUILDING ' � � OAD D R ESS� ,� Certified copy is filed with the county building inspection ��� NUMBER FIXTURE OR ITEM • FEE deparhnent. WATER CLOSET LOCALITY '�g�, _��� ' Da[e Applicant NEqREST . BATH TUB CROSS ST. CERTIFICATE OF EXEMYTIQN FROM WORKERS' COMPENSATIONINSURANCE SHOWER OWNER 1 L ' ' MAIL f (Tl�is section need not be completed if the work involved �LAVA70RY qooaeSs t�t� +� �... ��- � by the permit is for one hundred dollars ($100) oi leSS.) SINK Ci r7eL. ' C,�j I certify that in the perfurrnance of the work for which this DISHWASHEFi - � CONTRACTOR � permit ic issued,i shall not employ any person in n.�manner � .. � ,�,,,,� O so xs tv co subject to the.W rket'Compe aGon Laws. CLOTHES WASHER h j aooRes 6ate��1�Appticantt,� SWIMMING P�OL RECEPTOR � �/� LLi NOTI .E T APPLICANT:IF fter m ki thts Certiticate of ����, CIT TEL.N�. "Tb� ^ n' Exemption, you should becomz subject to the Wurkers' LAWNSPFiWKLER5Y5TEM - � Cnmpensation provisions of the Labor Code,you must forth- STA E � � �� LIC. /� with cnmpty with such provisions or this permi[ sha71 be WATEfl HEATER LICENSE NO. CLASS deemed revoked. OISTRICT NO. ,¢f{ACE5S �BY GASSYSTEM OUTLETS �. F� i y� / fj � - LICENSED CONTRACI'ORS UECLARATION OUTLETS OVER ' �L' � Z1 LL'y�[.��,�+—... T hereby affirm that I am licensed under pruvisions of Chapter �PER SYSTEM � ' . 9 (commencing with Section 7000)of Diaision 3 of the f3usi- f� - �/ FINAL � `�� � ness and Yrofessions Code,and my license is in Ful!force and �r�'f� `�����'N `T�� �ATE ,�y� ��,� VALI DATION � effect. J FiNAL � � License Number����� I.ic.Clxss � By ;� �1 � ,f �--x;_ Contrnctor Date � ' � � I am exempt from the ticensing requirements as I am a Pian check fee licensed architect o[ a registered professional engineer pLUMBING PERMIT ISSUWG FEE$ acting in my profeesional capacitY (Section 7051, Bus- r `t` iness and Professions Code). ;•�-�. TOTAL FEE ��� ; x/�� Lie.or Reg.No. Date plan check appiicant HOME UWNt�.N-HUILUEK DHCLAItATION . Name i hereby aff"um that I am exempt From the Contractnr's /address � License Law for the following reason (Section 7031.5, Busi- ��t� Tel.No. nessand Professions CoJe): � � I,as owner of thc property, am exclusively contracting -�G'] j,'�� with licensed contractors [o construct the project (Section 7044,Business and Yrofessions Code). �-� • • � • .Jr . GONSTRIIC7iON LENDING AGF,NCY �-• a 1 6:5 p I hereby affirm that iltere is a eonstruction lending agency , for the pedurmance of thc work for which thia peunit is s s o "� E.J(�L 3ssued(Sec.3097,Civ.G.). Lender's Name 1 ����i.—u� Lender's Addiess . - I certify that I have cead this application;md etate that the € above information is correct.I agree to comply witL all County SEF.RF:VERSE FOR EXPLANA'1'QRY LANUU.4GE � ordinances and State taws regulating Ptumbing, and hereby . authorize represeniati es of this County to enter upon the above-ment' .e3 prep ty fo:inspectian pu^ cses. �' � gnature f P mittee Date � ! � i •��i�� � �s�'pa.r` o K �o� "�"s�m� E > � i. A O O � +.� ��.~„� � O n`�0 6'y�C1.yo� x cu.. O � L d� O . � . � . . . . . �� ''P�" ,. O � �� �.O 't I". a we G� 0� .O r. 5 sMv s3u � > �. `� b . 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