HomeMy WebLinkAbout1153A (5) N'ORKICRS'COSf{'fiNtiAT10NDECI.ARATION �na���w ^
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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
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