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HomeMy WebLinkAbout1771A (10) "'°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 APPLICANT 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�clion n��d nol b�comp�eted II fha work inrolwd by {�� �hs permit b ier en�hundr�d dellon(SI00)or less.) tnvaiORY . D�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 • - ' � � ✓ '. p C G� � � O r O �n '�' !� A � �qjf � � T �O q � �f . `� � � m 7 � � � G � � � < y�'G ` ^ � .G�.. �0 �' O q � � Z A N , � .-.. � Y➢ - ?- C q� � � ' . � . Nr � m Jp O '^ �' L O , • D .� � . " ,,, , , � '�'.. . t ,:�i• , c � � ... '� . . . . . � N . � . ~ � � `2 � ' pA uf N m i �+ " � O � � , , �, � '.. •�;, p :. `,. c�"n ;�`r; "f . . ", ,,./. . ` Zu+ �. n . o A !j+ . . � � m N �� � . • , - .' " �r � . . . , p p � N ?� . _ � N(1� G G 7 V � . � � O���� �M''��9 !u N � •6G . ' . ? O;W, u� O p 7 p�� p O � '� . - � �`p O m � �,? 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