HomeMy WebLinkAbout1771A "'°RKERS•`°^"�"SAT'°"°E�`"RAT'°" � APPLICATION FOR PLUMBING PERMIT �
I hereby affirm that I have a cer�ificate of consenl to self �aqyy�q
insure,or a cerlifica�e of Workeri Compensolion Insura�ce, CE Bq(REV.10/BI) . . .
or a cer�ified co ihere i 1a6. � � - -
���5�[;��'���� COUNTY OF LOS ANGELES BUILOING AND SAFETY
P❑olicy N . Company
Ce�lified topy is hereby furnished.
FOR APPIICANT TO FIIL IN(PRINT OR iYPE) BUIIDING /y�,�,
�--Certi(ied copy is Tiled wilh Ihe county building inspea � ADDRE55 I � ��`��'�
tion depor 1. � /� NUMBER FI%TURE OR ITEM p FEE . .
.'�l 7�� ��L! �2 WATfRflOSEi LOCALITY � � .
Da�e Applico NEAREST
CERTIFICATE OF EXEMPTIpN FROM WORKER' BaTH iuB � CRO55 5T. ����C!y.� h��-
COMPENSATION INSURANCE OwniER � �
SHOWER
(Th��t�tlion n��d nol b�completed 11 fha work inrolwd by MA` {��
�hs permN b ier en�hundr�d dellon(SI00)or less.) tnvaiORY . AD�RESS ��� ��"1�
I ter�ify rhot in fhe performante of the work for which ihis
permit is issued,I sholl not employ ony perwn in any monner SIaK tltt `fv`�,� TFL.NO. ` � „
so as to bacome subjecf fo fhe Workers'Compensolion Lows. DISHWASHER �� ���/�
CONTRACTO t�
Dale. ePplicont CIOTHES WASHER ADDRE55 p. �
NOTiCE TO APPUCANT: If, ofter moking �his Cer�ificote of SwiMMMGP00LRECEPTOR �
EKemption, you should become su6ject to Ihe Workers' ,..,�k�-+t,
Compensolion provisians oi the Lobm Code,you musl forlh- . ��TY 7FL NO. ����� .
� LAWNSPRINKLERSYSTEM
with comply wilh such provisions or this permif shoil be STATE /�1`Z �iC. ^�
deemed�evoked. � WATER HEATER - LICENSE NO.—i J � �� CL455�6�
UCENSED CONTRACTORS DECLARATION � DtSTeKt ta0. PjtoCE55E er �
I hereby oHirm lhpf I om licensed vnder provisions o(Chop�e�9 - � GAS SYSTFM OU71E75
(commencing wi�f�$etlion 7000)of Division 3 oi 1he Business OUilETSOVFR �
and Professtons Code,ond my license is in f�ll force and effect. 5 P[R 5v57EM FINAL
l DATE VALID ION
License Num6er��` ��� lic.Clas�z� ���f�� O
/' ��,p U.'
-� FINAL
Conhacrdf�5��� -aij�rA-' � � 61' � � �
� � O
I om e*empi undar Sec.
Ws.Ba.C.for+hts reason plan check fee � a,
Date: p�UM&NG PERMIT ISSUING FEE E � Z
Signature . —+
TOTAL FEE I_n 1 7'7 � .
. � � � � Pfori check appiitont � i7 • ' 1 tx��
SINGLE FAM�LY • � C}5 O=
HOME OWNER-BUILDER DECLARATION Name � � � � . . . • • c�
I herehy affirm�ha�I am ezempt lrom the ContraUor's litense Address - - � ��,Q$—$7
Law for Ihe following reoson(Section 7031.5,B�siness ond . .
Professions Code): �;� �
❑ , y Tel.No.
I,oa owner of ihe prape�ly,will do Ihe work ond the
structure is not imended or oHered fof�sale(Section �
7044,Business and Professions Code�. - ' � � � - � � �� - - � � . "
CONSTRUQION IEN��NG AGENCY
I here6y nHirm that ihere is a construction lending agenty fo� � - � � - -
Ihe performance of the work for which this permil is issued �
(Sec.3097,Civ.C.). .. . .. . . .
� lender's Nome ... . '.. - - .. _ ... .... .. .
Lender's Address � �- �- - . � �
I certHy thor I hove read�his opplication and s�are�hot rhe ' ,
obove informofion is torrect I agree�o comply with all Co�nty � - � � � � � - � � � . . _
ordinances ond Stote laws re9ulofing Piumbing,ond hereby ,
authorize represeNotives of this County�o enter upon the . � � . . .
aboVe-meni�one�roper�y(or�r+specuon gvrposes, r, � SEE REVERSE FOR EXPLANATORY LANGUAGE
1j�1 i-��--�If
Signatu�e of PerrAitip Date • - ' � �
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