HomeMy WebLinkAbout1058A (5) 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
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� 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.
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