HomeMy WebLinkAbout0912A (4) w'ORKt:RS'COMYF.'vSATIOVpE:CLARATIOh �••••�• qpPLICATION FOR PLUMBING PERMIT
I hereby affirm that I hace a'certificete of mnsent to seif ce�n(z-eo) �
inwre,ur a certificate of Workers'Compenutinn lnxurance,or
a certified copy ihereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Yolicy No. Company
� Certified copy is herehy furnished. FOR AGPLICANT TO FILL IN(PRINT OR TVPE) BUILDING �}
❑ ADDRE$S � J ~11 U\(y,�
Certified copy is filed wi�h the coun�y building insDectinn NUMBER FIXTURE OR 17EM • FEE
�lepartment. LOCALITV 0.
WATER CLOSET h✓�
Datr Applicant NEAREST
BATNTUB CROS35T �
CF.RTIFIC.4TE OF F.Xf:MPTION FNOM WONKERS'
COMPE!�S.4TION IKSURAVCE SHOWER OWNER �'+y.Q
MAIL
' (ThIS 6eCtlOn nced not Ile Compleled if the wD�k invOlvld LAVATORY I ADORESS ��� • R : � ,�r.
by the permit is fo� one hundrcd dotlus (5100)ur lesa) SINK �
I CITV w N TEL.NO.�� (�
� 1 cerlity that in the perf�rme e f the x�ork fnr which this DISHWASHER ( • C
! permit is i+sued,1 ahall nM em y person in any manner COroTAACTOR K ;0�1 V• L Q
so as ec e subject to thr ompens ion Lawc. CLOTHE5 WASNEF F—
/� ADDfiESS `�pC`�) a�y U
I)afe 'O�Appiicant gWIMMING POOL RECEPTOR � v
a
!JOTIC T APYI.IC,i*IT:If, '�8 this 'rtificate of CITV Q y�,� p.r� 7EL.NO.Q�'��"� y
F.remptinn, you shoul� be me suhjccf lo th Wnrkers' IAWN SPRINKLER SVSTEM —I 0 STATE. LIC. n� �
Cumyeu.wli�m yru�i.�iunx uf e i.aiior Code.Yu ue[furtn- -- "" i— UCENSE NO. ��5�6� CL SS —/�•
W�i1h comO�Y w'ith such pror ' s or th- rmit xhall he WATER HEATER
deemed revnked. GAS SVSTEM OUTLETS I DISTRICT NO. P CESSED BV
I.ICk:\SEDCONTR.�CTOR511F:CLARATION OUT�ET50VER � .CLGs.sLr�
f herchy atf'vm that 1 am licensed under prnvisions otChapter 5 PER SVS7EM
� 9 (commencing u•ith Seclinn;000)�t Divisiun 3 of the Busi� iINAL �. i VALIDATION
ness anJ Yrofessions Code,and my licrnse ix in full force and OATE �, ���� �
effect.
LicenneVumher^�'"��� I,ic.Clasx �_�� F�NAL �
BY �J
µc ,.��- y "1 ��
c��i�a�m �
� I am exempt from Ihe s�ng reyuirements as S am a Plan check fee
licenxed architect or � registered Dr�fersionat enRineer pLVM81NG PERMIT ISSUING FEE S �
scting in my Profesxionat cepacitY(Section 705�, �uc- .
iness and Profescionx Cnde). � s� '�''^ � �"
TOTAL FEE
[' • •,• . c
Lic.o�ReR.N�. n�te Plan chack appliceni
}IOME O�l'\ER•BUII.DF.R DF.CL.4RATION
Nama �' � �1���>G
AddrYac � ' � � ^.��J'J
1 hereby affirm that 1 am exempt (rom the CnntracMr'.r
License I.aw for ihe fotlow�ing reason (Section 707L5,Busi• Citv Tel.No. �.�.'i^�j
nexs and Yrofnssions CoJc):
� f,ax ow•ner ot�he property,am ezclusively c�nlractinp
with licensed c��ntractors to conslruct �he prnject
(Sectiun 70as,Busineas and profeccionx Code). .
CONSTHUCTIOY L1iNDISG AGIiNCY
1 hereby atfirm Ihet there is a conxtruction lending agency
for the performance of [he w•ork for u•hich this permit is
issucd(Sec.3097,Civ.C.).
[.endePs Name "
Lender'x AJdrrss
1 cer'fy Ihat 1 hare read this applintion and state that the �
abov 'nfmmation ix correct.I agree tu comply.vi�h atl County g�_r K�VF RSC FOR EXPLAYATORY I.ANGUAGF.
nrdi� ces and 5totc lau•s regulatinR Plumhin¢,and hereby
auth representatire this Counry• cnrer upon the �
abuv lione eriy fur insFrction pu pus .
Si re a erm� ee te ' '
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