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HomeMy WebLinkAbout1153A N'ORKICRS'COSf{'fiNtiAT10NDECI.ARATION �na���w ^ ��.: 1. i hcrehy :dfinn ��„� f hace a certiticate a<<����� ��zr�< <E.,,�=-.o, APPLICATION FOR P�1.�1/IBING PERMIT �� in�urc,or a certificate nf Workrrs'CompensAtion Insurancc,or " �� a certi�e<f cov>'thcreof(Sec.�eoo,Lan.c.) COUNTY OF LOS ANGELES BUILDING AND SAPETY u 1'oliCy Ko. ComOany. � � CP�I1TICt�C1)�tY IS hPfOM1}'�Uf �s FOR APPLICANTTO FILL IN(PRINT OR TYPE) BUILDING - ADDRESS O S �Ce fie c�py ic filed w'it c unl il• ncp:ction NUMBER FIXTURE OR ITEM • FEE. � �'��e art LOCALITV WATEii CLOSET I)ate ApFliranl NEAHEST BATH TUB CROSS ST. ��} � . � CIiRTII'IC:�TIi OF F:KT�INT�ON FROM k'ORKICItS' � — . COMPIitiS,1T10N INSURA1vCL SHOWER OWNER LAVATORV I MAIL } (This vecNon need not be cnmpleted if the work involved pDDRESS a by thc permit ie for one hundred dollara (5100)or iess.) SiNK I � O CITV TEL.NO��.�� U I cPfiify fh:�t in�he peT(nfinenre nf tl�c w�<�rk f�>r x�hich this OISHWASHER I � pe.rmi[�s isaued,f shali not empiny any�persun in any manner CON7RACTOR � so ss[n hecome suhjc[t In Ihe R'nrker6'Cnmpencalion Laws. CLOTHES WASHER I A�DRESS lv 9 �p ' U I)ate Applirant SWIMM�NG POOL RECEPTOR I a � '�OTICF,TO APYI.ICANT:lf,afrer making U�is Ce.rtificatr of CITY TEL.N(�y,�JJ y Lxemption, you should hrcnme subjact tn the N'nrkers' IAWN SPRINKLEFt SYSTEM I � I $TATC i LIC. p Z I :':::i•����:;�•� P�:���.;�o�b�rf liir i.ai�ur Cotic.you must forth• UCENSE NO.�/ � CLASS G V� with comply w�ith such prm'isions nr ihis WATER HEATER permit shall be � �fJ� decmeJ rr�'nked. GAS SVSTEM OVTLETS I DISTRICT�NO, PRQICESSED B�' � I.ICICtiSCDCO:rTR:1CTOR5DIiCLAR.�TfOh OUTLETSOVER f, if—,1r'-�-+.,•—C-i � 1 herchy affirm Ihst I nm lii�ensed under pro��isions of Chapter 5 VER SYSTEM I7 (cnmmencinq x•ith Sectimi'000)nf Uieision 3 of the Ausi• FINAL nrss end Pm(ecsinns Code,and m)'Iicense is in full fnrce anJ I DATE � q 8 a VALIDATI N eHec[. Z �Q�/I.�C. FINAL I.ic�i}�(J9u�'d{'�S�f'�T:'� r*:l.Claec � BV �+� .�0-`). �,�„t����AST GRarr��r,v[�s,;�d:� _1[_l� . 1 �L 1F'LE CITY, Ci�.IFr)��"�: Plan check fee '�/� �� �''W`� I—���Z� , I,am ecempt from Zhc fh:btl.�idg requirements as I am a licenscd architecl � a registered F«>faasional engineer pLUMBING PERMIT ISSVING FEE$ actinG in my pmfescional cepocity (Sectinn 7051, B��s� ineceanJ YrnfesxinnsCnde). TOTAL FEE �� I.ic.�>r Rr{c.Vo. [)atc Plan check applicent IIOS7C 0:5'ti�R-BU1I.ULR DIiCL.4R.\TIO\ Neme Z� � �J�i I herehp offirm tf:at I :im exemp[ frnm thr Confrzcmr's Ad�'eu ^• • • • •5 l.icense Law for the fullow�ing rrason (Settinn '071.5, Busi• Ciry Tel.No. � � �� 2 5 Q nrss and Pmfessions CoJe): ` � 1,as ox�ner nf the proper�y,am excluSivCly contnctinR '' �t j� • • • � 2 J Q� with licenud mn�ractnrs lo consttutt Ihr pmject •"��11 )r (Scctiqn 70AG,Buciness and Prnfecxinns Code). �� F[�'��� �+•:.•,,,� �2 2 9�$� C� . CO\STfil1CT10\I.[:NI)I:YG:AGI:NCY ���� �"�"' � �.�.. 1 hereby aflinn thaf lhere is �tonslruction lendinq ngency for the perfnnnance of the work for u�hich this perrnit is issued(Sec.3097.Civ.C.). Lendrr's N�mc � Lendrr's Address I 1 certify�h�t f havc rrad �his��.I � on and xtate�h�t tlie ahove inf� a � ic correct.I r t �nmply w�ith all Cnunty SF.E RF.VF,HSE 1'OR iiXYLANATORY I,ANGUACF, ordinan a a A �[e u•S gu � Plumbing, and ereM1y authnr'c re rc Inl �s o ll- C ty to entrr u n th ahoc en ine pro ty e on purposes. , Z �/ \Signalut d f'crmittee Date �., ��',;r� J{1i�1�1C �,�. ::7 j r ;bt `,c.�� ^��', -� G t��r1`-�-c � i'C, �i ��r.':_'I -� L Z t' : G � �C f '< <v ��,r?1-1 ,1� ''L ��. 1 � n .t ... c: z. ' ' y,„!� 1. �7' �iyi1='�, ,'G C u, =.:✓� .1 ;O C1�,� . • ��� 1 � � r ,T^,�,` G��T . V 1 � ��� �."��� I' � 'fl t ,1�"' � � .. � r .1� � � �1 ' ! �,� '�� � .. - � � . � ' ; , ' ' ; 1 � I � ��i : �., . =` '. ,' � �_:,--,—; ; ! �c. a ` �.:. � � t �1 1 1 °. . m ' i'f a �� ° � � � ;. �� � ' � t 1 ' 1 =a ` � ,' ��:: o� : � ' ; 1 � ' ,`1 � . 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