HomeMy WebLinkAbout1425A (8) WORKERY�oM�N�,TioNo�w�,T�oN � . . . APPLICATION FOR PLUMBING PERMIT � _ � �1
I heroby affirm thM I hare o certificcte of mroent to self yaqbp�q � .
inswe,a o tertifiome of Worken'Compensation Insurance, �gV(REv.�0/Si) � � � , , �
or o cenif�ed eoPy�he.eof fs«.se0o,lab.c.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
�olicy No. . CAmW^y � � . � . . . . . . . � I
CerNfied cqpy is hereby fumished. BUnDING �
� Certified c �A���T TO fLLL M(PRIM OR TYVE) � � �p�� d �� .�.� , i1.�,,- �/ �,
opy ia fifed with tha counry building-inspec- ' i
fiondeportmenf. � NUNIBER . FIXIUREORITfM - � � �p�,q��TY �% �� I
WAhR CIOSET �
�e _ APPIiCanf � . . . NFniffST � ' . i
� CERTIF�CAiE OF FJ(EMPTION FROM WORKERS' �T�'�T� - ���. ,
1
- � CAMPENSATION INSURANCE SHOW.ER 4W�ER � � _ � '
(This�ectlon need not M complN�d tf thowark�mrolwd by . - j
th�permit b for on�hvndnd dollan(Sf00)or(�ss.1 � uvArortv q�pp��5. 1 "� i'b '�
I eenify�ha1 in the performanea of th9 work fcr which this . . •. . � +
permit ia iu�ed.I shall not employ any panon in uny monner SINK �� . pPt r,;,t;� � 1E1�� � C; —
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- w os to become subiect�o iha Warkeri ComPemation lpws. uiSr�wnSMR �p� C.�`-K�- �
�`{Dura�.�.Appliwn'_ ..-!' 6 uoTHESwnsHEk � nooRESs . .� .;
� NOTIC�TO APPLICAM:if, a er moking�� ' �tertificate t �
' Ezempfion, yo� nhwid becoma-s�bjetin ths Workers' � SN7MMINGPOQLRECE➢fa1
Compensafion provisiprp of Ihe taba Goda,yoy must foAh- � . �'�.�
� lAWNSPRIFMIERSY57EM �
with compiy wilh euch pmvisiwn or this pertnu ahaYl 6e � {TAiE i1C. �
deemed rerqked.. � WqTERHFqTQt V���� U^ss '
LICENS�EONTRACf4R$OE�IARATIQrI - 06TRltt NO. ; � P�S�D 8Y J
I hmeby affnm thaf 1 am licemed�nder proiiaions qf S,hap�ar 9 , ��M WT� � � 1�y�_ � ;
(rommencirg wi�h Sxrian 7C00)of Oirision 3 of tha Brrsineu punErs Wpt . d
nnd aofeu�om Gode,m,d my tkerrse ro m fuu force m�d eBx+. s PE�srsr¢nn flNlu VALIDATION � �
license Nvmber ��c.Closs - - � . � . �� . . C) ,
. . . . '.FINAL � O �
Connada- � -Dalle � . �.�Y .� .
r+ � ;
❑ 1 am exmp�undx Sec.� � .� .... . . . . . . . . �-
e.sa.c.fwrh�9.�o� plancheekfies `(/ ��� "
. �Q: � PlUMBING PERMIT ISSUING FEE S .�� ��. . 1
Signature� ,. ` . . j
TOTAL FEE � �
�
.. . . . _.... . . . Plan chedc appBcanf . � . � � �
SINGIE FAMILY . �
HOME OWNER-BUILDER DECLARATION �^�e - � - ' � � � �1 �.2 5 A - �
I hmeby effirm rhat I am e:empt 6om rhe Contracror's Lice�ne . � , - �
law for tha fo�lowing reoyon(Section 7031.5,Businms and �rh3- � �+• •.• . •5 ;
Profess7orK Code�: Gry � Tel.No. . . � �
� 1 • •1650 �
I,as owner of the propeny,will dv the wo�k and Ihe . �
- chucrure is nat intended w offered for sale(Secrion ..... � _ � , _ •..a �1 ��O U. I
� 7041,Businena o�Professiom Code). - . , I
mwsrnucrrorv�oiroc nc�wcr 0 2 0 7—8 4 ;
I hmelry affirm thot�hera is o construcfion le�ing agancy for, � . ;
tAe pe�formance of tha work for which�h7s permit is iaeued .- � - ?
ISec 3097,Civ.C.). . . � •
j
Lender i Name ' � I
le�e[s A�dress . � ' � . - �
I certify thal I hava read this applica�ion a�d stofe thm the . , �
above informo�ion is correcl.I agree M compiy with all County .
ordirwnces and 51afe laws regola��ng Alumbing,ord heroby � � �
auihorize represeMatims of tbis Counfy to anrer upon �he - � �� � � . � � " ' � � '�
a6ove-mentioned prope�ry f ' apecr�on purpoaes. $EE REVERSE FOR EXPLANATORY IANGUAGE �
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