HomeMy WebLinkAbout1783A (10) `"°RKERS•�°'"°E"5^T'°"°E«A"^T'°" APPLICATION FOR PLUMBING PERMIT �
I hereby affirm iha�I hove a cerrifica�e of consent to self �bq6y�q
ins�re,or o certiiicote of Workers'Compensafion Insurvnce, . CE BI7(REV.IOi81)
or a cerNfied copy thereof�$@�BpQ,,,L C.) � •
��v�'C�C�Z.��76� ����j� COUNTY OF LOS ANGELES BUILDING AND SAPETY
POol��ty No CompanY .
Cerlified mpy is hereby furnished.�
� FOR APFIICANT TO FILL IN(PRINT OR TYPE) qpDRE55 L J '
Certified copy is filed with�he couNy bvilding inspeo-.
lion depaffinent. . NUMBER FIXTUREORITEM p' FEE
��,�J � lOG4liTY (,.
�a�eJ�LApplicom WATER CLOSET NEAREST ^',
� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB � CROSS Si. � !� ��d J��t
COMPENSATION INSURANCE � - OWNER �l
SHOWER
� (Thb��Hion nMd no1 be complated it tha work inve r�d by MAiI '�p�qr
eh�p�nni�is for ona hvndrid dollan(5700)or le�s.) (AVATORV ADDRESS
I cer�iiy tha�in rhe peiformance ot ihe work for which this
permit is isi�ed,1 sholl nal employ any person in any manner SINK CI7Y f.r+L`In /J TEL.NOt�-�� �
� .�.C�
so as to become subject to the Workars'Compensalion Laws. DISHWASHER /+��` � ��.
� � � CONTRACTOR L�����/
pofe ApplicaN �� CIOTHESWASHER ADDRESS // �i ��J�� /J
NOTICE TO APPUCANT: If, of�er making this Cerfificote of � �/a 'jT�lilOe�
Exemption, yo� should become subject lo ihe Workers' SWIMMING POOI RECEPTOR
Compenzation provitions of 1he lobor Code,you musl forth- UTY r/j� TFL.NO.
IAWNSPRINKIERSYSTEM � �4
wilh comply i1h such provisions or fhis permit sholl be STATE �j 7 T'- LiC. �y �'J �
deemed�evoked. � , wATFR HE�TER IICENSE NO.��// C.�� Ctq$5 Li CT�� .
LICENSED CONTRACTORS DECLARATION oiSTRiCi nro. E55eD Y
1 hareby affirm Ihot 1 om licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS . � •
(commencing with SeUion 7000)o(Division 3 of ihe Business ouitEi50vEa
and Professions Code,ond my licanse is in f��l fo�ce and effect. s aeR SvsrE,�n FINAL VALIDA N
�/'� �� /p DATE p a
License Number"'������-/✓ Lic.Clasi.�� r r��� O
co�„a��'�'`�'�''✓���, 1�7``67 eYa` c�.
�
❑ I om e:empt under Sec. - �
. w8.8P.C.for this reoson plan check fee ► �y�.
Da1e: pLUMBING PERMIT ISSUING FEE§ � Z
Signature � � � ,
TOTAL FEE �+*��A��
Y
� � Plon chetk appliconi � j (,
SINGLE FAMIIY • • I 7C�v?
HOME OWNER-BUILDER DECLARATION Name-� � � Q�,O H—S^I
I hereby offirm ihat I am evempt from ihe Comrodor's license "
i.. ,r.. .�..,�_ii' --- - -- --s ard Address
r-y re..,,,� (S �,�..�......�...,w.���e, . . . . . �
Professions Code�,� �;iy Tel.No.
❑ i,os owner of the property,will do the work and the � �
s�ructure is not inrended or offered for sole�Section � .
7044,Bu4ness ond Prolession5 Code). - � �
:ONSTRUCTION LENDING AGENCY
I heraby nffirm ihot there is a mnstruclion lending ogency for � � � �
� ihe performance of the work ior which this permit is issued �
(Set.3097,Civ.C.�. . . . . .- .
lender's Name � � - � � ' - '
lender's Address � � � �
I certify iho�I have read this oppl�corion and srate�hat the � ,
abvve informo�ion is conect.�I og�ee�o mmpiy with oll Covnty � � � � - - - � - � � . .
ordinances ond S�a1e Iows regulat�ng PIum6�ng,ond hereby � '
authorize representotives of ihis County�o emer upon�he -- . . . .
obove-mentioned property for inspection purposes.
� } � � SEE REVERSE FOR EXPLANATORY LANGUAGE
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