HomeMy WebLinkAbout1311A APPLtCAT14N FOR PLUMBING PERMIT � � '
WORKERS'COMPENSATION DECIARATION -
I hereby afYirm thot I hove a cRrfifimte of conxnt ro self �yq66jp i
i�swa,or a certitiw�s of Workeri Compe�ation InsuraMv, .(�ei7�REV.IOiet) � � ' � �
or a cen�fied copy�he.eos(Sec.3800,tob.c.) COUNTY OF LOS ANGELES BUILDING/tND SAFETY ''
P❑olicy No. Company � . � . � . �
Cerfified copy is hpreby furniahed.
❑ FOR APPLICANT TO FILL M�PRINT OR TYPE) BUIIpING
Certified coPY n filed wilh ihe coun�y 6uildirg inspx. �� '� �
tion deponmen�. � NUMBER fl%TURE OR ITEM � pEE
iooum �
wnreR aosEr �
DoTe Appli4ant � �ry�q� r
CERTIFICAiE OF EXEMPfION FRC1M WORKERS' BaT�i tU8 . CROSS 57.
COIWPENSATfON INSURANCE �WER OWPffR ,� . . !
(Thta-sectlon nead not b�eompldtod if tfn work Invelved by .
ths p�rmit is fo�ene hu�red doflers(5100)or Ins.) � LAVATORY
�ss 2 �
I certify thar in the performance of�Ae work ith ihia
permit is is�ued.I shall no1 em ny on n n er �NK CITV r, 1F(. .- -1 _
no as to 6ecome subject�o or om . . '�
DISHWIcSHER CONiRACTOR� d r �T
Dote �. Q �+ pplicon � ' � CLOTHES WASHER �
NOTI�E TO APPLIG4M: If, aftn ma rh� enifieare of �� T �1- �
�Eaem tion, � SWIMMtNGPOOLREGEP7pR f
p you should be�ome su6'ect m ihe Worken' ���.,, �� � �1 �
�Cp,mpeneofion prorisions of Ihe labor C.pda,Yo�must forth• � LAWN$PRINKIER SYSTEAA � � A�n J� . I
wilh comply with such prorisiona or fhis permif shull ba SiaTE �K.
deemed ravoked. � � wp��,� UCENSE NO. � C1ASS —
- UCENSED CONTRACTQRS pECIARATI�IV � DISIRILi NO. CFSSED 6r i
I hereby affirm thpt�om IicanagA urider provisiom of Chopler 9 - �5��"� �T� � . Qp . .
(commanci�with Section 7000)of Qivision�of ihe Businen p��py� �O � I
and Professions C-0de,ard my licerae a in f�il force qndeffect. S PER SVSTEM F�I� VALtDAT10N O `
LicenseNumberl�----�ic Class � ` � �.� �
�Jno�b�k���� + aa OY FlNAL o :
�o�TMa�o, B� ►- �
u
❑ I om exempt under Sec. � p�, �
B.dP.C.fw ihis rcason � .. , � _
_ Plon sheck fea �1 3 1.1 A j
ome:
PIUMBING PERMIT ISSUING fEE S (O .5'�� �
. ..Siemh,.e . �• • • •+-5
. . - . __ . i4TALFEE �� �. . ' . i
_ I.• •2250 �
. ' . . . ' Plon check applicani . .- - . . � �����d ��,
SIfVGIf fAMIIY ,L,K/'r •�i �2'2,rJ�� �,
HOME OWNER-BWIDER DECIARATION Nama � � � � di- . ;
1 hereby affi�m thot I am eKempt from the Contracror's License A���s ' � ��.��:.�(y �
low for the foilowing reason($ection 7IXi1.5.Business and � � j
Rofessions Code): . Ciry Tel.No. . . � /� �� �
❑ I,os owner of fhe propeAy,wHl do�he work o�tha � - �/ . .. . � i
i
shuUuro B no�intended or offered for wla(Section . ► � � ,
70�4,Business and Profesaions Code). . . ' . . . . - . '
CONSTRUCTION IENDING AGENCY . . , . . . . _ � . _ . . j
I hereby affirm thaf Ihere is o canslruclion lending pgency Fa . . . �
� ihe perfMmonce of ihe work fo�which Ihis permit is isaued __ . , _ _ _ , _ _
(Sec.3097.Civ.C.): . � .
lender i Name . . . . . � . ... . . .
Lender's Address � . . .
I cer�ify thal I have read this application and ala�e that ihe � , .
above infpmotipn is torre[I.I ogree fo comply wi1Fi oll County � . .. . . . - .
ordirwrxes ond Sto�e Inws regulating Plumbing,and hereby
authoriza representotives of ihis Counly to enler-upon Ihe , � � . �
abore-mentioned property ior inspeclion parposes. � - � -
SEE REVERSE FOR EXPLANAiORY LANGUAGE
Sigaaturo of Pxminee Date . . . . . �
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