HomeMy WebLinkAbout1769A (10) w°RKERS•�°^^PENSAT�°N oE«^RAT�°N qppLICATION FOR PLUMBING PERMIT � �
I hereby offirm that I hove a ceriificote of consent to seli 7ypyy7A
insure,or a certifitate of Workers'Compensation Insurance, . CE Bt7�REV.t0i81)
or a c�f�d c�yp,��he�e�ot;S 800,la .C. � �j COUNTY Of LOS ANGELES BUILDING AND SAfETY
(iK�IC.'�'�'w� �j��,(��
P❑olicyl�r. Compony �-�-"�"/ �,
Ce�tified mpy is hereby furnished.. V
QFORAPPLICANTTOFlLIIN�PRINTORNPE) BUILDING 1`7'T� j,�p.�� � ,lJ
Certiiied copy is filed with the coun�y building inspea ADDRE55 L C/J W`�'�--
lian d�e�pcar�tmenf: �NUMBER FI%TURE OR ITEM (rD FFE ����T� � �!�
,�yl_ ` ! 1/v1�„ �,_n VC%L'C�I1CJ
Dale Appii4a+1' ���� K'ATERCLOSET NEAREST J ���,�r,� �
CERTIFICATE OF EXEMPTION FROM WORKE ' BA7HTUB CRO55 Si.(./���—'Y Q~� ����
COMPENSATION INSURANCE . � OWNER ��..e -
(This�eNien n»d net br cemplN�d if Ih�werk nvolrad by SHOWfR /� =
Ih�p�rmil�s for ono hundrad doilara(SI00)or Ims.) LAVAtORY DDRE55 �VI� � ,
I certify that in rhe performance of the work for which this ,
permil is fssued,I sholl not employ ony person in any manner SINK � � � ' CITY� I �'V'Ne� TEL.NO.
so as�o become subjecl to the Workers'Compensa�ion Laws. �
. DISHVJASHER � CONIRACTO y�01
Dote- Applitoat ' CLOTHES WASHFR ADDRE55 �� I �Q(
NOTICE TO APPLICANT: If, after moking this Cenificole of SWIMMiNGPOOLRE�EPTOR
E.emp�ion, you should become subject lo fhe Workers'
CITY ����'�/l� TEL O. �:
�Compenso�ion provisions o(Ihe lobo�COde,yoV mpsllorlh- NSPRINKlER5V5TEM �
with comply wi�h suth provis�ons or �his permit sholl be Sinte �r�7,/�Y_"i uC.
deemedTVORecI. ' ' WATERHEATER ' L�CENSENO.`�� ✓ .J� i.ass G�-�
IICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY.
1 hereby oHirm thot I om litensed under provisions of Chapter 9 - GAS SYSiEM OUTtETS '
(commencing with Sec�ion 7000)of Divis�on 3 of Ihe Business OUTIETSOVER
ond Profeuions Code,a�d m license is in full force^and e�H--e�ct. 5 PER SYStEM FINAL \I/��� TION
licenie Number—I�• �� Lic.Class�"-" � DATE �� O
`����-��'l) FINAL U.
Comroctor �� . er �-
� v
I am e:ampl under Set. �.
U
B.SP.C.for�his reason � W
Plan check fee � ��
D�1e' PIUMBING PERMIT ISSUING FEE 5 Z
SignoNre
TOTAL FEE
. . Pladcheck applicam . . . :g� 7 6 9 A
SINGtE FAM,ILY �
HOME OWNER-BUILDER DECLARATION Name � - �.' � ' � '5
I heroby offirm thot I am exempt from tha Con�rottor's License Address � � • • � [�5�
law for�he following reason(Set�ion 7031.5,Business and � �
. Professions Cade): � Ci�y �. Tel.No. � (z �
I ❑ I,os owner of 1he property,will do Ihe work and ihe -" 0�,��—���
structure is not intended or offered fo�sale(Section �
f � 7044,Business and Professions Code). � � �� �
f CONSTRUCTION LENDING AGENCY
I I hereby nffirm that there is a conslrutlion lending agenty for
? the performance of the work ior wh�ch fhis permit is issued
� (Sec.3097.Civ.C.).
ILender i Namr. .. .. . .. . . �... . . .- . . .
1
I lender's Address , - � - - � �
1 I tertify Ihai I hove reod Ihis opplimtian and sta�e that�he ►
above informa�ion is mrreU.I agree to comply with oll Coun�y ' � � � � � �
ordinances and Srate lows regulaling Plumbing,and hereby -
autharize representaiivez of this County io enler upon ihe ' �
above-mentioned�roperty(or inspec��on puiposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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