HomeMy WebLinkAbout1615A �"°RKERS"`°"^PE"S"T'°"°E�`"R^T'°" . APPLICATION FOR PLUMBING PERMIT �
;e hereby affirm that I have a certificate of mnseni in self .:76nbmn
�" insure, or a cerfificate of Workers Compensation Insurance, -:GE 817(REV.10/81) �
or a certitied mpy thereof(Sec 3800,tab.C.) COUNTY OP LOS ANGELE$ BUILDING AND SAFETY �
. �cy�vo.6Fi73t��,'��mpa„y S'i/4T� FtJA;!? �
Certified mpy is hereby furnished. �
� FOR APPLICANT TO FlLL W(PRINT OR TYPE) BU�LDWG �} i „/
Certified copy is filed with ihe-counfy building inspeo ADDRE55 ���-I ��pf�ti ����� 1��+•
tiondepaftmenl. NUMBEF FIXTUREORITEM Cn FEE _
�/ LOCALI7Y �}��/1,1CJ�I] 13A�
'�- Date �j Applicant_aC•�ti�_(�'j{� Wa7ER CtOSE7 _ NEAREST } �
CERTIF�CATE Of EXEMPTION FRO ORKERS' BATH TUB CROSS 5T. Q���p r D I�IFl lUC �
COMPENSATION INSURANCE OWNER (,J f(J�Ai VfN� �
�- (This soction need not be completed tf ihe work involved by StiOwek Rl C'M g�
. the ermit is Eor one hundred dollars 100 Or Igss. MAIL f �
p {S } ) tAVATORV ADDRESS.ZrIL`) fN(JfRN G'lQC�IG �C(Y �.
- I certify ihai in ihe perfarmance of the work for which this rt
permit is issued,1 shall not empioy qny person in ony manner SINK CITY �1���ti,� 17��lC TEI.NO ;
$ f-/7
so os!o bemme subject to the Workers'Compens�tion Laws. DISHWaSHER �
corvTkc,cTOR 5•{J/�i.3E�NG ��V CfJ�S%�
. Date .__Applicanf CLO7HES WASHER ADDRE55
NOTICE TO APPLICAN7� ff, atter making this Certificate of t«� �.`L!�}l��/'�f:l\:1 f��,
- Exemption, yov should become subject to the Workers' SWIMMINGPOOIRKEPTOR
- Compensafion provisions of fhe Labar Code,you musf forih- (qWN SFRINKLERSYSTfM CITY d7��AA�Mi� TEt.NO.f � r�� �
with mmply wilh such provisicns or this permit shall be e �� �
. STATE t IIC. p
dee,med revoked. WATER HEA7ER LICENSE NO. '�'7�'�.Z 7 CLA55 V
LICENSED CONTRRCTOR$DECLARATION DISTRIQ NO. �PROCESSEO BY B
1 hereby affirm that I am licensed under provisicns of Chapier 4 � GAS SvSiEM 1 OUTLETS � � �
. (commencing wifh Section 7ppp)of Division 3 of fhe 8usiness OUILE7SOVER � {!
-- and Professions Cade,and my license is in fuN force and effect. 5 PER SYSTEM OA E� l� � VA IDATiON � E
� License Number�l�^ �� ! lic.Class� � � V �
- .5 iJA/SONCs ` �j � A fINAL �� / ' � I
Contracror �L/ �(-'t?NS7R Date� BY �yV�.� � � �
�- ❑ I am exernpt under Sec L �— � t
� �
�
B.&P.C.for}his reoson � �
Pian check fee
Da1e: `�
PWMBWG PERMIT ISSUING FEE S j ��`G .�1 0 1,5 A �
Signofure �-
. TOTAL FEE � �f w a o +, m y, �
� Pian check appllcant �
�
. SINGLE FAM��Y I * ���,::�(':
� HOME OWNfR-BUILDER DECLARATION Name � -
i hereby affirm ihat I om sxempt from the Controctor's License °C��{'�i
Law for fhe following reason(Section 7031.5, Business and Address . s�¢
_ P
Professions Code}: [i�y TeL No. ���•�-�`���''J
❑ I,as owne�of ihe proper�y, will do ihe work and the
- siructure is not intended or offered for sale (Sedion ►
- 7044,Business and Professions Codej. � �
CONSTRUCTION IENDING AGENCY - .
-I hereby affirm lhat ihere is a mnsirut'ion lending agency for
the perfarmance of the work for which this permit is issued
(Sec.3097,Civ.C.). �
Lender's Nnme
Lender's Address �
I certify ihai I have read Ihis application and state ihat the � ,
abovc information is mrred.I ngree io<omply with�II County . �
ordinances or,d Stote laws regulating Plumbing,and hereby
. auihorize representafives of ihis County to enfer upon the �
cbove-menfioned property for Inspection purposes. .
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature Permittee Date . t
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