HomeMy WebLinkAbout1731A "'°RKE"5•`°"^`E"SAT'°"°E"^""T'°" ' � APPLICATION FOR PLUMBING PERMIT
I here6y oifirm tho�I have a certi(icole of conseM�o se�1 �hA��q
insure,or a certifimte of Workers'Compensolian Insuronce; CE 817(REV.10/81) , �
or a cerriRed copy+nereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �
P�olity No. Company
Certified topy is hereby furnished. BUILOING c n
FOR AGPLICANT TO FILL M(7RINT OR TVPE) ADDRESS O A� �T�
� Cer�ified copy is filed witF��he co�nry building inspac-
liondeparlment. . - � NUMBER fIRTUREORITEM @ FEE �«p,�ITY r�r174�� �
Date q Ii an1 WATERCIOSET �
aa 4 caossssr. C�} ,�J" O G' �
CERTIFICATE OF EXEMPTIQN FROM WORKERS' . BATH 7U8 ,
COMPENSATION INSURANCE OWNER � /N � L /
� (Thb s�clton n��d nol M complef�d Il lhs work involwd by SNOWER
fh�p�rmif Is for en�h�ndr�d dollan(5�00)or Is�s.) LqVATORv ADDRES$J��1' ' D�L�
I terfify Ihol in Ihe performonce of the w for whith fhis -
permif is i55ued,1 shpll not amploy any par n In ony momer SWK � CITY J/J 7EL•Np'G�iO/�
- so as to bacome subject to the Wor pensation laws. �� " ��
v � DISHWASHER CONTRACTOR � ��
Da1e� Applica G�LL ` � CLOTHES WASHER A�DRE55
NOTICE i0 APPLICANT: If, a er m ing rhis Cariificoie of
Ezemption, you sho�ld become subject to �he Workers' SWIMMINGPOOLRECEPTOR
Compensolion provi5ions oi Ihe La6or Code,yau must iorth- � pTY 7EL,Np,
LA W N SPRINKIER SYSTEM
wi�h tomply wilh suth provisions or this permit sholl be STATE LiC.
deemed revoked. - WATfR HEATER I�CENSE NO. CUSS
. LICENSE�CONTRACTORS DECLARAiION DiSTRiCT n10. PROC D ev .
I he�eby offirm thpf I em licensed vnder provisions of Chopler 9 GAS SYSTEM OUttET$ j O
(commencing wiih Settion 700p)oi Division 3 of the Business OutIEiSOVER �
ond Professions Code,ond my I�cense�s in(ull force and effect. 5 PER SVSTEM fINAI VALIDATION
license Num6er Lia Class DATE � O_
FINAL V
Conlracror �aie . BY �
❑ �
I am e*empl under Sec. OO�
w
e.aa.C.to��h;s�eoson Plan check fee ,
�:.
Do�e: p�UMBING PERMIT ISSUING FEE b Z
Signoture � .
- TOTAL FEE a .
. . .... .. Plan check applicant � .
SINGLE FAM4Y
HOME OWNER-BUILDER DEClARA1ION � Nome � �
I hereby affirm�hat I om ezemp�from ihe Comractar's license� Address �
law for Ihe following reason�Section 7031.5, Business ond -
❑Professions Code): City Tel.No. �.� .��, A
I,os owner of the property,will do�he work ond ihe
strocture is not in�ended o�offered fo�sale(Setlion , � �� � � � �Jt
7044,Business and��ofesstons Code). � � �
CONSTRUCTION LENDING AGENCY _. . , . I • •3�.5 0
I heraby nFfirm thot fhere is a tonstruclion lending agenty for -
1he performance of Ihe work 1or which ihis permil is issued •�� •J Q�J Q c=i
(Sec.3097.Civ.C.�. . ....... .. . . . .
09.08--86 '
lender's Nome - . � �� � � - - �
lender'sAddress � - " � � � �� � �
I certify thot I have reod this opplicorion and srate ihot the .
obove information is correct I ogree io comply with oll Couniy �
' ordinances and S�ale laws regulating Plumbing,and hereby
outhaize repres ntatives of ihss County ro en�ei upon the � � . . ,
abov nrio perly for inspeclion�qurposes. �
// SEE REVERSE FOR EXPLANATORY LANG�AGE
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