HomeMy WebLinkAbout1718A (10) woRKERS��°^^�NSAT�°N°E«^RAT�°N ` APPLiCAT10N FOR PLUMBING PERMIT <�a S�S �
I�hpreby-Gffirm ihat I have a cerliiicole of consent to self �yya�q
insure,or o certificate oi Workeri Compensalion Insurance, CE BV(REV.10/81) :
or a cer�ilied copy ihereaf(Sea 3800,La6.C.� �pUNTY OF LOS ANGELES BUILDING AND SAPETY � � � � '
Q�YNo75oZS� Company 5�7� /�iv� . ... . ��� S
Certified copy is hereby(urnished.
FOR APMICANT TO fllL IN(PRINT OR TYPE) BUIIDING
�'Cerffied copy is fited with the munty building inspec- ADDRE55 S]
fion departmenL -- -�• - NUMBER FU(TUREORITEM (� FEE �«A�ITY a .
WATERCLOSET � �
Date Applicom - NEAREST ,f '
CERTIFICATE OF EXEMPTION FROM WORKERS' � BATH TUB � CROSS Si. A ` ( �,
COMPENSATION INSURANCE SNOwFR OwNEe � ..,_. '
(This�.clion n�ad nof b�eempl�f�d if fh�work Involved by nnniL �
th�p�rmft ls lor ons hundred dollen(5100)or Iefs.J LAVnTORY ADDRE553I S �Qly /9 ��"f -
I cer�ify thot in fhe performante of the work for which ihis � �
permit is issued,I shall no1 employ ony person in ony mannar SINK - - CITY � EL NO. �_
so os to become subjecr to the Workers'Compensation Laws. DiSHWASHER -
. . . CONTRA�TOR �.21V. � �+ AS q K .
Dale Applicant CIOTHE5WA5HER ADDRESS � -
NOTICE TO APMICANT: If, offer moking this Cerlificate oi ,
�nption, you should become subject to the Warkers' SWiMMINGPOOLRE�EPTOR
arr rei.rw.6y —S
�pe�solion provisions oi the Lobor Code,you musl forth- LAWNSPRINKLERS�STEM
with comply with such provisions or this permit shall be � STaTE liC.
daemed revoked. � WATER HEATER LICENSE NO. � CLA55 C
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ��SE�BV
I hereby affirm�hat I am li[ansed under provis�ons o1 Chopter 9 GAS SYSTEM OUTLETS �—
(mmmencing wi�h Saclion 7400)of Division 3 of Ihe Business OUiIETSOVER
ond Professions Code,and my I�cense is in iull forca and effect. 5 aER SVSTEm FINAL VALIDATION
DATE }
License Number 3� 3� Lia Class Ca7 O .
FINAL U.
�'�T.�w�./ LR.vilsc�/oF.. q BY
Conhatlor / Do1e • `�_� �.^ -
� O '
I am eKempf under Sec. U
8.8P.C.for this reason W -
Plan check fee ► . N'
Date: p�UM81NG PERMIT ISSUING FEE 3 � `� - Z _
Signat�re
TOTAI FEE b �
- .._. . - . .. . . . . Ptan check oPPticant - . . - . . . . - � 4
SINGIE FAAIILY
HOME OWNER�BU�LDER DECLARATION Nome . - . - � ,
�''•eby aFlirm 1ho1 I am exempt from the Coniractor'z License � �
y�for the following reason�Section 7031.5,Business and Address � �
� Pru{assions Code�: Ci�y Te1.No. � . .. . . . . . ' ;�1 7 1,8 A f
❑ I,as owner of the property,will do Ihe work ond Ibe "� � �� � ' ' �
shuclvre is nof iMended or offered(o�sale(Sec�ton , N• • • °!'S -
70a4,8us�ness and Profess�ons Coda). . - - � � � � -
CONSTRUCTION IENDING AGENCY - � ' ' � �J O ;
1 heraby nffirm thot fhere is a cons�rodion lending agency for � � �� . e •w � �5��
fhe per(ormonce of�he work for which this permit is iss�ed
,��.��,���.�.,. . or.00�os
Lendei s Nome �
lender's Address � � - - - - � -� �
1 cerlify thol 1 have read ihis application and sfate that the ,
obove informolion is corrett.I ogree lo comply wifh all County � - - � - -
ordinantes and S�ale laws reguio�ing Plum6ing,and hereby
auihorize represen+alives of rhis County to emer upon �he . . . � . -
above-meNianed erty for ins ec�on purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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