HomeMy WebLinkAbout1779A woeKeRs coM�NsnnoN oec�ARnnoN APPLICATION FOR PLUMBING PERMIT �
I hereby affirm that 1 have o cerr�f�coie of consent to self �aqyb�q
insure,or a certifitate of Workeri Compensalion Insurance, � CE BI7(REV.10i81� .
or o ce.ti��dtcp����ni�5se-3floo,}o�q.C.�� �� COUNTY OF lOS ANGELES BUILDING AND SAFETY
1S�- 6�p�,Y� (1,v�..�
P❑olicy t6o."' Compony
Certified copy is hereby(urnished. BUiIDiNG � �7���,
FOR AP7LICANT TO FlLL IN(PRMT OR TYPE) ADORE55� ��/ �� C.W��r(�Yj
'�_Certified copy is liled wi�h the couniy building inspeo-
�iondeporlmenl ' //n NUMBER FI%TUREORITEM �rD FEE
i-l7--�'7� '�-�C.C� �«A��T� ,-,
Do�e qpplicon � WATERCLOSET NEAREST /"�,., ��
CERTIFICATE Of EXEMPTION FROM WORKERS' BnTH NB CROSS 5T. L���e" �S✓ I Y��
COMPENSATION INSURANCE � OWNER �
SHOWER
(This�actfon need no1 6�comp��fod it tho work inr �d by nv il .t��� / �) �
�h�p�rmit is For on�hundr�d dollon(5100�or I�ss.) l.qvniORY . � ADDRE55 C (
I cerlify thol in the periormantr.af fhe work for which Ihis
pe�mil is issved,I Shpll no�employ any persan in any monner � SINK CITY v��� TEI.NO.�
so as ro become su6jeU ro the Workars'Compensation Laws. DiSHwnSNER � /A� �I� r/�., �,
� - CONTRACTORC.lI � C. 7'1-'� �
Date Appliconl CLOTHES WASHER ADDRESS �/� , GG ,,�
NOTICE TO APPLICANT; If, o(1er moking this Certificote of SWIMMINGPOOLRKEPTOR ,/
Exemption, you should become subjeci to the Worke�s' CiTY iEt.NO. $ /
Compensation prvvisions of Ihe la6or Code,you mvs�forlh- � �qyyN SPRINK(ER SYSTEM � •���
wi�h comply with s�ch p�ovisions or Ihis permit sholl be SiATE L� ��3 LIC. (V
dCBmed levOked.' . WATfR HEATER ' LICENSE NO. CLASS `J
IICENSED CONTRACTORS DECLARATION DISTRICi NO. E55E0 6Y
�I hareby oNirm thal I am licensed under provisions of Chopfer 9 GAS SYSTEM OUTLETS
(commenting with Sec�ion 7000)of Division 3 oi�he Business OUT�ETSOVER
and Professions Code,ond my license is in full force and effect. � 5 aEk SvSTEht iINAL VAII TION
`� DATE O
License Number ✓ � Lic.Class� . /—/2—�
��,��_F-1_ __D�.�„ ,� / _J FINAL U.
Contra T (-��l�L, a`}8� By a
� U O
I om exempt under Sec. �
6.8P.C.foi IhiS reason Plan check fee � a� �
Dale: ptUM81NG PERMIT ISSUING FEE E `1 .�7 9� Z
Signature
TO7AL FEE
�. . . . .5
- Flan check appiicant �
� SINGLE FAMIIY I • • � �i 5 O
HOME OWNER•Bl11LDER DECIARATION Name � - .
I hereby afiirm thal I om erempt from Ihe Conlratlor'S Li[ense Address • • ° � �5�_
- law for thc following reason(Sedion 7031.5, Business and . —
Professions�ode): City Tel.No. 0 1.O II—8 7
❑ I,as owner of Ihe property,will do 1he work ond the � � - - - � �
struclure is not intended or of(ered(ot sale(Section �
7044,Business end Profess�ons Code). � - - � � � �
LONSTRUCTION IENDING AGENCY ,
I hereby nffi�m ihat there is a cansiruUion lending ogency for � � � ' �
ihe performance of the work for which�his perm�t is iss�ed
(Set.3097,Civ.C.). . . . -
lender's Nome � � � .
Lender's Address ' � �� �
. I certify thot I have read ihis applim�ion and s�aie thai�he � .
ahove informaiion is correU.I agree�o comply with all County � � � - - � - - �
ordinances ond Sta�e lows regulo�ing Plumbing,and hereby �
au�horize represenralives oF rhis Couniy to eNer opon Ihe � . � . . . _. ,
a6ove•menlioned prope�ty for inspecfion porposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signolore of Pr.rmittee Dote � � - � .
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