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HomeMy WebLinkAbout1058A u'ORKERS'CO'MPF.ISATIONDI:CLARATIO>7 �.•�•,• , APPLICATION FOR PLUMBING PERMIT 1 hereby affirm tt�a[ 1 I�are a certificate of consent to self ce nr�z-�o � insure,or a certificate nf�tbrkers'Cnmpensation Insurancr,or a certified copy ther of(Sec.3900.I,ab.CJ '��cV�,�/zy�6�'`�mFanY� � ✓�q( COUNTY OF LOS ANGELES BUILDING AND SAFETY +r � CcrtificJ c�py ic hcrchy furnishecl. FOR APPLICANTTO FILL IN(PFINT OR TYPE) BUILDING �j �Certifled cnpy is tiled w•i[h the cnunt buildinp i ection NUMBER FIXTURE OR ITEM • FEE ADDRE55 ��7 r r S �C�/ �fe artm t. / LOCALITY I)ate,f�.,Y'� Appiic�nt � WATERCLOSET ryEAREST ��J �� BATH TUB CROSS ST. � CGRTII'iCATIi OP GXGSIYTIO�FR M N'qRKFRS' CONP[:tiSATION INSUR:'�NCI SHOWER OWNEF � �- LAVATORY MAIL �` (This seclion need not be completed if the work involved � � pooRE S �-f'y� � e�fp� � a liy thc permit is for onc hundred doilars (5100)or Icas.) SINK � I I CITY �{�M2 TEL.NO. �- U I certi(y that in lhe prrfnrmance of ihe a�ork fnr u�hich lhis DISHWASHER I I I /� � pennit is issued,1 sh�ll nnt employ any person in any manner CONTRACTOR _!^ s � Q 50]5 IO become subject to the R'orkers'Compensatiun Law�s. CLO7HES WASHER I I ADDRESS Gi�f—� ��y��� U na�e :\pplicinl �� Z �v • ��/ �/� ul SWIMMING POOL RECEPTOR I d NOTICI:TO:\PI'I.ICA'�1T:If,af�er making this Certificate nf CITV ���p N� TEL.NO.�fy� s�/ � I:xemption, y�u tlt�:ilti becnme Suhject t� ihr �4'nfkef5' LAWNSPHINKLERSVSTEM I �` z STATE --7�/ p(� LIC. C �C� Cumprru�tiun ptnrisions of the Iabor Code,you must fnrth• yJqTER HEATER LICENSE NO. 7'�S �,� O 1 CLASS � with romply with such prorixionx or ihis permil shell he Jccr�cd recokrd. GAS SYSTEM OUTLETS � DISTRICT NO. PROC SED BY t LICEXSG.UCO�ITR.4CTORSDi?CI.ARATIUN OUTLETSOVER Id .�l�-t'`"Q'� 1 h ly affirm lhal 1.m licensrd undcr pm��ixionx�CChapte� 5 PERSYSTEM 9 ��mencing with SecGnn 7000)nf Di�ixion 3 0(the Busi� �7 FINAL � n ,h�1 lk��fessirmx CoJe,and my license is in full(orce and �r4 Uv DATE l—�����Z VALIDATI�N c�ect. / ��f S C�SC N'�"r � FINAL l.icr sr Vum Lic.Clusa BY J Cfi��F�oi��� Dare_(h�J���� � I am ezempt frnn Ihe licensing reyuirements es 1 am a Plan check fee licenseil architrct or a re}tistered profexxiunal engineer pLUMBING PERMIT ISSUING FEE E atting in m}• professional capacity (SrcHon 7051,Bus- S'', iness and Nrofessions CnJe). TOTA�FEE �� U I.ic.or Rr¢.\�i. 1)ate Plan check applicant liOSiGOR'NI?R-PUII.DLRDI�.CI.ARATION Name 1 herehy nffvm Ihaf I am e<rmpt fmm Ihe Contnrtm's A�����ess ���c�sa License I,aw tnr the follow�ing rrason (Srction 7031.5, Husi� City Tel.No. � ncss ond Rofessions Code): #'�'��• • •5 � I,nx ou•ncr of thc pmpr.rty,am ezclusiecly contrecting with licenxed rnntractnrs to cnnstruct the project �'�'�� 2 5 Q (Scrtinn 7D94,Ruxinexs and f'r�fessions Code). CO\STRUCTIO\LI;NDIIG AGf:NCY � � ' '� 2 5 O� i1 hereby af(irm lhat there is �construction lendinq agency �''I ' '�i 8 1 for the per(onnance of the w•ork for u•hic:i this permit is ISSIIC<I(StC.3OB7,Civ.CJ. LenAar's\amr LendePs Address 1 certi(y thot I ha.�e rcad Ihis applicstion anJ state th�t lhe abore infnrr.iation is correct.I agree In comply with all Cuunty SFF RF.VBRSf 1'OR[iXYLANATORY LAKGU:IGli nrdin;mces :md St�tc Iau�s regulating 1'lumbing, anA hereby . nuthnrize rrpr ilalivrs � t ' County to enler upon the sbovr�mc ' propc nspe i�n purpnses. / � Signnture of Ye mi�e / atc G '" `, O i; �Z��,\T'\^�O`q C'G�`r �?1 �� �� �,- .° :.� \ %�� C' �\G S ^\^ . 2\ �, ��'G% �,� \,c YO ` � '� 1. '"� ?.�? .r Y'�� �,`\ t' \ (l a ��. `' � C i t � ' �, �.. �� '�f . 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