HomeMy WebLinkAbout1127A WORKERS'�°^^PE^'S^T�°"°E��^RAT'°" APPLICATION FOR PLUMBING PERMIT {� �
I hereby affirm tha� I have o certilim�e of tonsen�to salf 7d4667q ��
insure,or p'Qeniiicote of Woikers'Compensation Insoronce, CE 817(REV.IOi81�
(oi�a carfified topy Ihe�eo((Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY .
���'��+?FG030S�-DCo��m�ooy��Tlv��sJl n ,ht ufu�YL—
Cer�iFied copy is here6y furnished.
� FOR APGLICANT TO FILL IN(PRINT OR TYPE) bUR�iNG �
Certified copy is filed with ihe to�nly 6uilding inspec- A��� G
lion deparlmenl. . NUMBER FI%TURE OR ITEM � �E �p�p,�ITY
Date R ag-g� WATERCLOSET � f� d� Mo�tID A
Applicant � NEARE57
, CERTIFICATE Of EXEMPTION M WORKERS' eATti 7U8 p CRD55 ST.
COMPENSATION IN ANCE ' SHOWER OwNER
(This�Mion nMd nol b�complN�d tf Ih�vrork Involv�d by �i�
Ih�p�rmN Is for on�Aundnd dol�on(SI00)or I���.) LAVATORY ('i0 qppRE55
� I certify thof in the performance of Ihe work for which this -
permil Is issued,I aholl not employ ony person in any monner SINK p CItY TEL. � _
- so as to become subject to�he Workerc'Compensolion Lawf. piy.pyqgNER
. ' (/(7 CONTRAROR um �
Dole Applicont � CIOTNES WASMER a '
NOTICE i0 APPLICANT: If, ofte� moking rhis Certificoie of A�� � �
Eaem �ion, ou �hould become wbect to �he Workeri SWIMMINGPOOLRECEPfOR
P Y I CITY TEI.NO.
�ompenaotion provislone of fhe labor Code,you musl fath- �AWNSFRINKLERSYSTEM � g �
with comply wi!h su:h prcvisler.s ar fhit parmil sFwll be STATE IIC.
deempd re�oked. WATER HEATER ���N��� 0� �
LICENSED CONTRACTORS DECIARATION �� DisikiCr r�o. � ESSFo Bv -
. provisioro of Cha GAS SYSiFA1 OUtlEiS �V
I hereby affi.m�hat I am Iiceroed undx pter 9 r/�
(commencing with Sec�ion 7000)of Division 3 of ihe Business puTtFiSOVER /O
and Professions Code,ond my licensa ic In full force ond effect. 3 PER SVSTEna � FINAL � tC �� VALIDATION y-,
.�rl J�IITD DATE p:
Lfcense Numbar Lic.Class� Q
a6.j� St��Y�B 7 BY AL U..
i
Commcfor r! �ote �
❑ 1 am e mpt under Sec. �'
U
8.8V.C.for�his recson W
Plan check fee ► LL
Da�e: N
PLUM8ING PERMIT ISSUING FEE S ('f � Z�
Signalu�e � ��
� TO7Al FEE ��� 'I Z 7 A
i
Plan check opplimnt � �
SINGLE FAMILY #• • •-• �5
HOME OWNER-BUILDER DECIARATION Nome - � I • � �l Z S O '
I hereby off�rm ihot I om exempt from ihe Comroctor's License - .
law fo.the following reoson(Secfion 7031.5,Business and Address ' .. .+ ,y �4 Z 5�� .
Profeuions Code): � � City Tel.No. 0�2 g�$,r
❑ I,os owner of Ihe property,will do the work and 1he .
strocture is nat imended oi oHered for sale (Settion , �
7044,8usiness ond Profassions Code). .
CONSTRUCTION LENDING AGfNCY �
I hereby nHirm that lhere is o comhuction lending ogency�or
the performonce of the work for which this permif is issued ,
(Sec.3097,Civ.C.). . . .. .
lender'S Nome
Lendei s Address ' �
I certify thol I hove read Ihis opplimrion ond s�ate thot Ihe ,
obove informarion is correct.I ogree�o mmply wiih all County � � �
o�d�nances ond State laws regulatinq Plumbing,ond hereby �
au�ho�ize represeniotives of this Couny�o ente�upon the
obove�meniioned properly for inspecrion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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