HomeMy WebLinkAbout1652A ""°RKERS•`°""'E"SAT'°"°E"A"^T'°" APPUCATION FOR PtUMB1NG PERMIT "
affirm iho�I have a cer�ificoie of mnsent ro self 76a667A
r o ce�tifitole of Workeri Compensation Insuronce, . CE BV(REV.IOiB
�f.ie�d c�op`y�f�he�r.eo�f ec.3 L b.C.) �
'P�—"`�ompa�ny��� ��I��W i� ��UNTY OF LOS ANGELES BUILDING AND SAFETY
�Ceriified copy is hereby fumished. , � BuilDwG
FOR APPIICANT TO FILL IN(PRINT OR NPE) 6� y• r
Certified copy is liled with Ih 6uild'ng ins a � ADDRE55
�/� ��ondeparlmenL � NUMBER FI%TUREORREM � (� FFE ��`TM �
�o�e�y �Z.APPIi m � WnTFRCLOSET �
NEAREST
CERTIFICATE OF E7(E TION f M W RKER BATH TUB Cri055 ST.
COMPENSATI RANCE OWNER �
(Thi�txflon nNd nof 6�aompbted if!he work Inrolwd by SHOWER ,
fh�p��mil it for one hundred dollen(5700)ar Ivss.) tAVATORY ��� -
I certify fhol in the perfor ance of the work for which this
ADDRESS
parmit is issued,I sholl nol mploy on person in any manner SINK CITY TFI.N0. G�
— w os fo betome subjatt t Ihe Wo�k s'Compensa�ion Lows. OISHWASNER �
�'e � CONTRAR �r i
plicOnt CIOTHES WASHER ADDRE55 �v S
NOTICE TO APMICAN If, of�er akir.g this Cerlifitote of SWiMMiNGPOOIRECEPTOR t
�Exemption, you sho d beco subjecf ro the Workers' . �iTy TEL NO. !—��
Compansotion provi ons Of th tabor Code,you musl forth• LAWNSPRiNKLER SYSTEM
with comply wilh ch provi ions ar this pe�mit sholl be STATE tIC.
deemed revoked. WA7ER HEATER LIGENSE NO. QA55 �"3
LICENS CONTRACTORS DECLARATION DISTRI�1 NO. P(70CESSED BY
I hereby affirm Ihot I om licenaed under provisions of Chopte�9 - GAS SYSiEM OUTlE75 /U
(tommencing with Section 700p)of Diviaion 3 of Ihe Business OUilEi50VER �
and Professions fode,and my license is in full force and effect. s aEa s SreM FINAL ��� V IIDATION
lice e Lit.Closs<—�G (/� DATE a,
FINAL �
nl or ore �j 1`�-�7 BY V'
� I am e.ampr under Sec. - � l/� �
O
B.BP.C.For�his reason � U
Plan check fee � W
n.
De�e: �-�� �
PLUMBING PERMIT ISSUING FEE$ Ip � Z
� $ignpture
TO7AL FEE � ',=� 6�.`2 A ;
SINGLE FAMILY P�an check applican� � r�,f• • . • i rj
HOME OWNER-BUILDER ECLARATION Nvme . I s �� Ct S O
I hereby affirm thot I am exemp�iro 1he Co raclor's License
Lew for�he i..lbw!ng.__.on(ce•pon 7031 9u:ine:s cr.d � Address . � ��n=
Professions Code): �^ �i�y Tel.No. + 1 M v V V
❑ I,os owner of the propen ,will d Ihe work vnd ihe �Q•� 4—8 7
strucrure is not in�ended r offer for sale (Sedion � ,
7044,Business ond Profe ions Co e). - - �
CONSTRUCTION NDING GENCY
I hereby nffirm thot there is o ons�ruc on lending agen[y for
the performonce of the wor ior wh h ihis permit is issued �
(Sec.3097,Civ.C.). - � � �
Lr,nder's Name �
Lender's Address �
. I certify thm 1 hove r d this pplim�ion and s�a�e thar rhe ,
above iniwmofon�s rreu,I ogree�o comply with oll Coonty �
ordinon[es and Slat lows reguloting Plum6ing,and hereby
ovt repre'sentotives of this County lo emer upon the . .
ove�men ned ropert f r inspectinn ourpases. �
SEE REVERSE FOR EXPLANATORY LANGUAGE
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