HomeMy WebLinkAbout1768A (10) WORKERS•�oMPENSAT�oNOE«ARAT�oN , . APPLICATION FOR PLUMBING�PERMIT {� �
I hereby ofiirm that I have a certifitaie of consent ro selt �bqyb�q . ��
insore,or a cerfificare of Workeri Compensalion Insuronce, CE 817(REV.10/81) . . "
or a cerr�iie/d�copy/ih�ereoi(Sea. Lobz.C.j`1(�//C� �,,� ��'/// COUNTY OF LOS ANGELES BUILDING AND SAFETY
P�oIi�YNoC/"/O'Z5� ompan�� �7 "' rQ"'-11- _
Certified topy is hereby furnished. U
� - ! FOR APPLICANT TO Fl((IN(PRINT OR NPE) BUILDING �ZG��-•( ���—� .
Cer�ified topy is iiled with the coun�y b�ilding inspec- ADDRE55 U
Da�e�1i n deparlm t. �n� NUMBER FI%TURE OR ITEM � FfE ����TY
Appli4on( ��f - WATERCLOSET NEAREST / �, '��
� CERTIFICATE Of EXEMPTION FROM WORKERS' ' BATH TUB CROSS ST.I.i��'�I������ 1�n�'
COMPENSATION INSURANCE - SHOwea OWNER ��
(This sMion na�d nof bs comp�efad if tha work inrolved by ' MAa ''7/� �� �,
the psrmit it for ons hvndred dollors(5100)or lafs.) . iAvarortv ADDRE55 � f_(�
I certify thot in the performance of the work for whith ihis
permil is issued,I shall not amploy any person in ony manner - SINK C�TY 1�� TEL.NO.Gi
so as fo betome subjecl lo rhe Workeri Compensalion laws. pi5HWA5HER
CONTRACTOR� -� .
pote Applicont � � � � � CLOTHES WASHER ADDRE55 `Gil� L{/� �
NOTICE TO APPUCANT: If, oNer moking this Cenificote of Syy�A1MiNGPOOLRECEPTOR
Ezemption, yov should become subjetl to fhe Workers' CITY �. � iEL.
-Compensation provisions of�he[obor Code,yoo most forth- LAWN SDRINKLER SYSTEM
winc �omply with wch p�ovisions or lhis permit sholl be � STA7E L1>1 7 uC.
deemed revoked. � WATER HEATER UfENSE NO. 7✓I � CL455 �
LICENSED CONTRACTORS OECIARATION DiSTRiR NO. E55Eo av
I hereby oHirm fho�I om litensed under prov�sions of Chapter 9 . � G.455v5iEnn OUIlETS '7 '
. (mmmencing with SeUion 7000)of Division 3 of the Business OuitEi50vER d� .
ond Professions Code,ond my license is in(ull forc/e�and effect. 5 PER SrSTEM FINAL VALID IDN
�I�S� C�O"� DATE � �� (]:
License Number Lic.Class O
/� p r/ 7 FINAI U.
Controctdi'��"���"�alE " "� BY �
❑ I om exemp�under Sec. �
8.8P.C.for ih�s reoson
Plan check fee ► d
�ore: N
. PLUMBING PERMIT ISSUING FEE$ _ �� `]6,S A Z
� Signoture - ' �
' TOTAL FEE � •
n• • • s �5
Plan check appliconr 1 • • 1 6 5�
SINGLE FAMILY
HOME OWNER•BUILDER DECLARATION � Name • � �J O c=i
I hereby offirm that I am eKempt from�he Contractor's license pddress ' •
Law for the following reoson(Sec�ian 7031.5,Business and � � O�,�$'$7 "-
Professions Code): Cily Tel.No.
❑ I,as owner of the properly,will do ihe work and the .
strocture is not iniended o�offered ior sale(SeUion ,
7044,Bus�ness ond Profess�ons Code). � � � ' '
CONSTRUCTION tENDING AGENCY . _ . . _ . . . . .
�he�eby nffirm thel there is a conslruclian lending agency(or
the performonce oi�he work tor which ihis permit is issued , _
(Sec.3097.Civ.C.). �
tender's Name
Lender i Address � � � � � �
' I certify thot I hove read th�s applimtion and srate tho�the � ,
above informa�ion is mrrect.I agree io comply with oll County � " �
ardinances and Slale laws reguloting Plumbing,ond hereby .
. avthorize repreienta�ives oi this County fo eMer upon ihe � - - � � .
bo e•mentianeiproperty for inspection pu�p05e5.
/_���`� SEE REVERSE FOR EXPIANATORY LANGUAGE
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