HomeMy WebLinkAbout0842A (4) ��'ORKGRS'COti1PEtiSATiO'd D};CLARATl0�1 veesnw ^
� �,e«hY nffirm �h�� 1 haee a'tertificate ,>����5�„�,�z��< <e.�,«..o, APPLICATION FOR PLUMBING PERMIT �i
insure,or a certificate of�Abrkers'Compensaiion Insurance,or ' ' ��
a certified c�{�y there�f(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY U
PolicY No. Company '
� Cettifird cnpy is hcrrhy furnisLed. FOR APPLICANT TO FILL IN IPRINT OR T�'PE) BUILDING n ,�" �
� NUMBER FIXTURE OR ITEM � FEE '�'DORESS SQ� �' /"/PVl .!C/-v/IJ
Cer�ifieJ copy is filed k•ith�he enunty Uuilding inspectinn � /�
�Ic�ariment. LOCALITY �//��CvoG Ia2
I1atc .\pplican[ WATER CLOSET NEAREST
BATH TUB CfiOSS ST. S!J^����r' C��Polf���✓ " �
CERTIFIC.ATF OF EXFNI'TIOV FRON N'ORKERS'
C0�1PEN5.\TIOti I�SUR.4NCl; SHOWER OWNER �3�(� (�/'yJ/�/r./
LAVATORY MAIL
}
(This sectian nced not he completed if the work invoived aooRe55 -S�/�+E a
by rhe permit is tor one hundred dollars(;100)or Ieat.) SINK I S9SG�2 O
CITY TEL.NO. U
I crrtity lhst in thc perfnrmnnr_D�IIIP u'O!I(�Uf ti��ICII II1I5 DISHWASHER �
pennit ic issued,I shall nqt empipy any persnn in any manner I CONTRACTOR Q(JN� �
sn at�o becqme cubjeCt to Ihe N'orkets'Compensation Lnws. CLOTHF.S WASHER �
Il AODRESS U
�ate —1�Ap�licant�(,�E�'Yln.� SWIMMING POOL RECEPTOR I a
\OTICii TO:�PPLICANT:If,afcer making Ihis Certificxtc nf CITY TEL.NO. tA
Exemption, you shoulA hernmc suhject tn the N'nrkrrs' �A�NN SPRINKLER SYSTEM I STA7E V.C. z
Cm:ipensnUou pro�isionx�.f liir Lai�or Cndc,you mus[ior[h- UCENSE NO, CLASS
w�i�h comply u�ith such provisinnx nr ihic pr.rmit shall be WATER HEATER I
Jeemr�rc��af:ed. GAS SYSTEM OUTLETS I� v DISTRICT NO. PROCESSED BY
LICLti51iDCOVTRACTORSDI:CI.ARAT10'v OUTLETSOVER ffl <��ttJ�Li
1 hereby nffirm ihat 1 am licensed under prnvixionx of Chaptrr 5 PER SYSTEM
9(commcncing u�ith Scction 7000)of Dieision J nf the Pusi- /��� � FINAL (�
nrss and I'rofescions CoJe,and my lirense is in full fnrce and � '�L� �L� �ATE �����''{L VALIDATION
cffrct. I
FINAL �
Licence Number l.ic.Ciasx Ay ��j f��(,(���
Contractor Dale
� 1 sm exempt from the liccnsing reyuirrments ax I am a Plan cheek fee
tiCensed architrct or a registered p�ofecxional enpineer pLUMBING PERMIT ISSUING FEE$ ��j
arting in my pmfeceinnal caparil3'(Reclion '051.Rus• '1
iness anA Professions Codc). TOTAL FEE �� �v
l.ic.or krg.Nn. Da1e Plan check aPPlicant
110.'dti0'd'NICWEUII.DERDF.CLARATIO\ Nnr�e
1 hereby af(irm thit I am cxempt frnm thr Contnctar's ntldress
I.icense Law fur Ihr follou�ing reason(Settion 7031.5, Husi� City Tel,No.
nes5 an�Prnfessi�ns C�de): ::C�',(,•r rI�
� 1,as owner of ihe propertY•am exclusively euntracting' . �
with licensed coniracturs to eonstruct the project � e • e • �
(Section 70a4,Ruainess and f'rofrssinns Code).
� � �x��
COySTRUCTIOV I.I:NDItiC.�1GI;�1CY
1 hereh)• affirm Ihal thrre is a canstruclion lending nRency ' ° ' � �'�(;"
for the performance of the w•mk for a�hich this permit is
iccued(Sec.J097,Civ.C.)• � �,�;.�^,,—Fj�
Lender's Yame
Lendcr'c Address
I certify Ihat I hare rr;id Ihis npF�ication and stare that the
sboce intormatinn ic correct.I apree to cumpiy«�ith all County S�r RFVi;RSti FOR IiRYLAVATORY LAVGUAGTi
�rJin�nces �nd State Isu•5 reRuistinq I'IumbinR, and here6y ,
nulhori:c representalirrs of this County to enter upon !hc
�boce.mrntioned property inr insprctian O��rposes. �
��'iG?�� 1/-3� - p/
Sienature of Prnniuee Date
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