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HomeMy WebLinkAbout1779A (10) 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. 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