HomeMy WebLinkAbout1774A '"°RKERS•�°'"'E"S^T'°"°E«^RA"°" APPLICATION FOR PLUMBING PERMIT {� �
I hereby alfirm ihat I ha�e o cert�f�cote of consenl ro self �bqya�q L�
insure,or a certiFimte of Worke�i Compensation Insurance, CE 8�7(REV.10/81� . . . _ . .
o�a cer�e�cop + {.5�c`3800,la�rC�.) ��2 n COUNTY OF LOS ANGELES BUILDING AND SAFETY
POolicy fSif��G Company r� F� X' . ..
Cerlified tapy is hereby furnished. ,�—
FpR APMICANT TO Flll IN(PRINT OR TYPF) g������'J��� ' '��l+l� �.�
Cerlified copy is filed wilh Ihe county huilding inspeo ADDRE55 < «�r
fion deporlment. �- - NUMBER FI%TUREORITEM (�D FEE , n I� ,I
� r�O� iocnurr r—
Do�e � �� AppliSa�— �`��"� WATERCLOSET, NEAREST �`J V l /
CERTIFICATE OF EXEMPTIpN FROM WORKERS' BnTH TUe CRO55 5T. �?'I�^'1�4 CC(J I'�Q—
�COMPENSATION INSURANCE SHOWER OWNER �`� ,
(Thit��Mlon n��d nof b�eompl�}ei!I!Th�work�nvolved by MAI� `�/� ^A
ih�p�rmit it feron�hundr�d dollors(SI00)o�Ins.) LaVAiORY �
A�DRE55 /—r� �✓1.I
� 1 cerfify that in the performonce of Ihe work for whichlhis
permit ie iss�ed,I shail not employ any person in any monner SINK ' CITV {V���I TEL.NO. ,���
-� so os b become subjecl ro�he Workars'Compenwtian Laws. pi5Hwn5HER
• . - CONTRAROR��/ ��.rl
Dale �pplitant CIOTHES WASHER ADDRE55 !LI�`l �
NOTICE TO APPLICANT: If, ohe� making thiS�Cerfifica�a of J
E■emp�ion, you should become sobjecr to the Workers' SWIMMING POOL RECEPfOR �
Compenso6on provisions oi fhe lobor Code,you musf forfh- LAWNSORINKLER SVSTEM CfTY �r��r �� ����
' wi�h comply wi�h such provisions or this permit shall be `�N� �� �K. �a� -
deemed ravoked. � WATER HEATER CUSS �
LICENSED CONTRACTORS DECIARATION DISTRICT NO. PROCESSED BY .
I hereby affirm that I am litensed under provisions oi Chapter 9 Ga5 SVSiEM . OUTLETS n
(commencing wirh SeUion 7000)of Division 3 of ihe Business pUTlE75OVER . V�
and Professions Code,ond m�license is in fuli force and effecl. 5 PER SYSTEM FINAL �//��� TION
�JI�J� .�/�� DAiE �., ..� O
License Numher / � Lic Clas �-7 ��7
��LCII��yt_f c J`�/`u/ FBIY Al U.
Comroc� �Ye - �.
❑ O
- I am e:empt onder Sec.
--- U--
B.BP.C.for this reason , a
Plan check fee
DO1e' PtUMBING PERMIT ISSUING fEE 3 Z
s�9�o,�,a �1 7 7.4 A —.
TOTAL FEE
� . Plon check applicani n�e i• s e�j
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Nome� - � I • • � �S O
I hereby of(irm Ihat I am exempt lrom the Conlrattor's license
low for Ihe following reason(Seclion 7031.5,Business ond Address • • � ' �5 0�
Professions Code): City Tel.No.
❑ I,as owner of the property,wfll do�he work and the ��,�8—II 7 .
srructure is noi in+ended or offered for sole(Section ,
7044,Business ond Profess�ons Code). � ' � �-- �� - -- �
� CONSTRUCTION LENDING AGENCY .. .. . .
I herehy n(firm ihat Ihere is a mnstrucfion lending agency(or � .
the performance of the work for which ihis permi�is issued . - .
(Sec.3D97,Civ.C.). � �
Lender's Nome
tender's Address - �
I certify that 1 have read thi:applicmion ond siate iho�the � ► �
above inlormmion is correcr.I agree�o comply wiih a��County � ��
ordinonces and Sto�e lows reguloting Plumbing,ond hereby
outhorize represemarives of ihis Coun�y to enter upon the - ,
ob ve•mentionedd opert ior ins'eUiory porposes. �
UvA�o� / 7 G"T7 SEE REVERSE FOR EXPLANATORY IANGUAGE
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