HomeMy WebLinkAbout1312A �WORKERS•�oM�NSAT�oNOE«ARAT�oN � APPLICATION FOR PLUMBING PERMIT !7
I hereby Uffirm 1hp1 I hove o cerlifitole oi consenl fo self �0-00�6 DPW 6187 �
. insu;e,or a tertifimte o�Workers'Compensolion Insurantt, 78A667A ' .
, or o certified copy rhereof(Sec.3800,tob.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS �
� P❑olicy No. Company . _ . � �
� Certified copy is hereby furnished. � �
❑ FOR APPIIGNT TO FILL IN(PRINT OR TYPE) BU�LDING hCr] `I`{•�y1.h�tn hn,
Cerlified topy is filed wirh the county 6uilding inspec- nDDRESS �-L� J W���Y��-��"' Y
tiondeportmenl. NUMBER FIXTUREORITEM � �E �p�q�itY �����
� Da1e qpplitan� '- WATERClOSET NEAREST
CERTIFIGATE OF EXEMPTION FROM WORKfRS' BATH 7UB Cit055 ST. �`"��
COMPENSATION INSURANCE pyy�q �� �M�, � ��
(Thl��Mlon n��d ee16�eempirf�d il fh�Mork invoiv�d by
SHOWER
ih�p�rmH I�lor on�hvndnd dollan(II00)er I�u.) , tAVATORY W �o�u �IL � �
I certify that In the performance e w k f r which this
permft Is iuued.I ihol)not emplo ny rib�in y ma�ner SiNK � [ITY TEI.NO. _
eo os 1 bxome b�ect to�he W e ' La�✓s. DISHWASHER CONTRACfOR �1{t11J�. ��,�}2
`J�ole ( �Applitonl �� CtOTHES WASHER
NOTICE TO A%. NT; If, ah - ktng �hh rtificate of AODaESS
E■emption, yo� �hould me b�xt fo t e Wwkeri SWIMMING POOL RECFPfOR
CompenwNon provieione of the la6or Code,you mual forrh• ��TM ��•�•
wifh com I with wch �ovl�lon� or this ermlt ehall be U+WN Sva�NKLFR SYSTEM
P Y P P STAiE uG.
dsemed�evOked. WATER NEATER ������ �u '
LICENSED CONTRACTORS DECLARATION DISTRIR NO. RtOCE55ED 6Y
I hxeby offum+ho�I am Ikan�ed unde�provisions of Chap�er 9 � ��s SvsiF�t ('OUT�ETS O
(commenclrp wilh SacNon 7000)of Divhion 3 of the Bustness OuitEISpYER
and Rofns7om Cods,ond my Ilcsn�e 1�In full face end effecL S PER Sr57FM FINAI�^7 Z�� VALIDATION o
Llcenfe Number Lic.Clafe DATE �
FINAL � U
�ontractor pote BY — � �
O
� U
I om e�empr�nder Sec.
6.8P.C.for lhls reo�on Plan check fea ► - y�
Date: pLUMBING PfRMIT ISSUING FEE S 0 �1 Z
- Signnlvre --
TOTAL FEE .LS' � -Q� 3'I.G A
Plan chxk opplicpm � -
SINGLE FAMILY II• • • • •J�
HOME OWNER-BUILDER DECLARATION Name "�^
I hereby oNirm ehat I om exemp�from the ConiraUor'e Licsnse p��e�s - � • •2 8.��
Low!or Ihe following reoson(Section 7031.5, Business and � � � �,��J C U
Professions Code): Ciry �� Tel.No.
�"� I,as owner of the property,wili do Ihe work a�d�h� �� p g,p� —g g
st�ucfure is nol intended o�offered fof sale(SeUion • , . �
7044,B�siness and Professions Code).
CONSTRUCTION IENDING AGENCY � �
�he�eby nffirm Ihot there is a construc�ion landing ogency for . �
the performonce of�he work for which this pe�mit is iuvad
�Sac.3097.Civ.C.). . . . .
Lender's Name � � �
Lender's Addrets
I cerlify ihol I have�ead ihis opplicolion and stote ihot the ► '
above i or o is correcl.I ogree to mmply with oll County � - �
ordin c s d tale ws regulating Plumbing,and hereby
aWhor' r of thys County to enter upon the . . .
obove- pe r inspecti n purp ses.
I SEE REVERSE FOR EXPLANATORY LANGUAGE
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