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 � !
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