HomeMy WebLinkAbout1767A "'°RKERS"�°'"PE"5^T'°"°E«^RAT'°" APPLICATION FOR PLUMBING PERMIT� �
I hereby affirm�hat I have a certiTicate of consent to self �yqyy�q
in5ure,Or o certificate of Workers'Compensalion Insu�an[e, GE 817(REV.10/BI� . � .
- pr o ter-fiyfia(d�to�py Ihereoi y(S�ec.3�a6.C._) � q A� �pUNTY OF LOS ANGELES BUIL�ING AND SAFETY �� �
P❑olicyNY/c-/!J`.'�"'�f�RY ���� . . .
Certified copy is he�eby furnished.
FOR i1PPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ^� �-��
Cerlified copy is filed wilh�he tounty buiiding inspec- AD�RE55
tion de rtm nl. NUMBER iIXTUREOR�TEM @ FEE .
� S/� �� LOC4LITY L(' �"��
..DaleJ_L_=.,LAppliconf rV� WAiERQOSET ' NEAREST �/ �7 �/�.� ^
� CERTIFICATE OF EXEMPTION FROM WORKfRS' BATHTUB - CROSS ST. (� a�� l.�/ I��`�
- COMPENSATION INSURANCE SNOwER OWrvER� �� � �
Qhis�oclion naad nof M compl�fad t/1h�work inv �d by ��� /�,/'� �'^ �
fh�p�rmif Is for ons hundred dollars(5700)e�lafs.) LAVATORY qooRE55 —L"l ���
I ceriiiy�ho�in�he per(ormance of�he work for which this . -
permil is issoed,I sholl not employ ony person in ony monner - StNK - Cliv /� '�,�� tEL.NO.
� so as fo bacome subject lo�he Workers'Compenso�ion laws. DISHWASHER
. - CONTRACTOR � _ �
Do�e � � ApplimN - CIOTHESWASHER ADDRESSt �,� - Le
NOTICE TO APPLICANT: If, afier moking fhis Certifico�e of �
Exemp�ion, you should become subjed to fhe Workers' SWIMMMG POOL RECEPTOR CI1Y TEL �Z 3
Comp@nsotion provisions of ihe Lo6or Code,you must forih• LAWN SPRINKLER SYSTEM ' ` �^--7 �
wiih comply with such provisions or fhis pe�mit shall be STniE ��'S3 C�SS(J C�
deemed revoked. WATFR HEATFR - LICENSE NO.
� LICENSED CONTRACTORS DECLARATION �ISTRICT NO. ESSED BY
1 he�eby affirm Ihot I am litensed under provisi0ns of Chaple�9 GAS SYSTEM OUTlETS - .
.(mmmancing wilh Seclion 7000)of Division$01 Ihe Business OUTtETSOVER �
ond Protess�ons Code,ond m li[ense i5 in full force ond effe[t. 5 PfR SYSTEM FINAL VALI TION
(��' � DATE �f p�j
license Num6er'4'��35 Lic.Class — "' � _!� " O .
FINAL U.
Confratt�-��������� BY O
❑ (�
I om ezampt under Sec. F-
U.
6.8P.C.for this reoson � W
_ .. . . Plan check fee � o.�
Date: � —
PLUMBING PERMIT ISSUING FEE E `� '��'�A ^
Signature
TOTAL FEE
�{. . . . .5
� Plan check applicanl � ��
SINGIE fAMILY I • • � �i Jr O
HOME OWNER�Bl11LDER DECLARATION Name -� � �
I hereby offirm fhat I am eKempt from the Contractor's license - � � � � � �5��
Law fo��he following reoson($eclion 7031.5,Businest ond Address .
Prolessione Code): Cily Tel.No. 0��Q 8,�8 7
❑ I,as owner of the property,will do the work and Ibe - - � � �
snoctwe is not iniended or offe�ed for sale(SeUion �
- 7044,Bus�ness and Profess�ons Coda).
CONSTRUCTION IENDING AGENCY
I he�eby nffirm thot there is a construction lending agency(or
the per(ormonce of Ihe work for which ihis permit is issued -
(Sec.3097,G�.C.�. . .._ . . . ..
Lender i Name � .
Lender's Address � � � � � � ' - � � - -
I certify ihat I have read ihis application end sta�e that the �
above informaiion is correU.I agree ro comply with ali Counry � ' �
ordinances and Sta�e lows reguloting Plumbing,ond hereby �
av�horize represenfo�ives of this County to enter upon ihe - � � � � � � � �
o6ove-meniconed properiy 1or inspe5ti purposes.
�� � �� SEE REVERSE FOR EXPLANATORY LANGUAGE
��
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