HomeMy WebLinkAbout0877A -•�F�f'�SATIONDECLARATIOV �e4a��w APPLICATION FOR PLUMBING PERMIT {�
have a certificate of cmiseart to uii ce n��z-eo�
�1 f N'orkers'Com��nsatinn InsurarKe,or ��
,�(.Sp��00,LaF.C.) (^
,��r` ��'(,1 1�-- COUNTV OF LOS ANGELES BUILDING AND SAPETY
1ri�•. -Compan, r���'1-��'I
;q�� n ,
_ �n.����'f is herehy furnisited. FOR APPLICANT TO FILL IPI IPRINT OR TYPEJ BUILDING ���/`: f������� '_ \
�r/��.��.' ADDRESS v ��;�( (..LJ
'r.•��,� (� �s fileS with t e cii t h IJinR ins�ecli�n NUMBER FIXTURE OR ITEM • FEE LOCALITVt ' , � T�
f�c ' 1/, WATER CLOSET w��'�v'
�� � .a�plicanl NEAREST
r/�r
I��`�� :.4Tf:01�f:Ct:�tYT10Y I�ROM WOR ' S' BATH 7U8 CROSS S7. �
�f r��^ COMPF.tiSAT10\INSUR.�NCE SHOWEF OWNER�Ay��
� MAIL
"��!r a nccd not bc com lelwl if the wuric imoived LAVATORY I `�J `�� ,�J }
D ADDRESS � r� d
'!'+i� mit is for one hund�ed dollers (5100)ur lesa.) O
��,, SINK CITV 1 I 1I�1 I .) ' TEL.NO. U
.nat in the pertnrmance nf the u•nrk inr u�hich ihis DISHWASHER I I I vv��v �
��;�,� sxved,1 shall not empl�y any pe�snn in any nlanner CONTRACTOR \
�ecmne sub'ad to�he u'IIfACfb�Com cnsntion Law•s. I I A�DRES ��� � �� O
1 P CLOTHESWASHER
�'r. :1PVlicant � �, W
,f SWIMMING POOL RECEPTOR I p,
TO.4PPLICANT=ff,nfter making this Cenificate nf CI7v �� _ 7EL.N , tn
�r � nn, ynu shoulJ be[nmc xubject to �hC l4brker5' LAWNSPRINKLERS�'STEM Z
setiuu rorisiuu�uf liir Lai,ur CoJr. — -------- STATE 'llvf cX // LIC. —
p yuu must fnrlin WATER HEA7ER LICENSE NO, d CLASS
� .mply with such prorisions or thix permit shall he
� J revnAed. DISTRICT NO. PROCESSED BY
+ GAS SYSTEM OUTLETS �/
[.1CFSSLnCOtiTR:1CTORSDF.CI.AR.�TlOU OUT�ETSOVEa I I I � � //e�f
:rehy affirm thst 1 am licensed unJrr provisions nf Chaptcr 5 PER SYSTEM � �
. �commencing��ith Sec�ion 7000)of Ui�ision 7 ot t��e Busb ` . � FINAL ����'j VALIDATION
'ess and k'rofessiocs Code,and mY���rnse ic in full force and .� �ATE O
effrct. / I
Lieensclumbr��` �C`� `£1aClass�� I FINA�
r 6Y
Contrect� �-�� ��Date S?-�1-���
� I a�n exBrt7pt from�he licensing reyuiremems as I am a Plan check fee • r�•,'?���
licensed architrct or a regixtered profexxiunal engineer ' � . . .�n �i
�ctenF in my rr�fec<i�nal capacity(Stelinn 7051, Nux- PLUMBING PERMIT ISSUING FEE S [:l � �
inecs anA Pmfecsinns Code). TOTAL FEE ��O SCJ
�..� ± <.��+
� I.ic.or Req.No. Date Plnn chnck applicant • � a i , ;�' -
� Ii0111:ON'NI:R•BI71L1)f:R I)I�:Ci.ARAT10\ Name ' n� _��.
. .:1 ,. �
� 1 hereFy �ffirm that I am exempt fmm the Contracror's AAAreas '
�� T.icenar Law fur ihe(ullmsinR reason (Secli�m 703i.5,Ausi• City Tel.Na.
ness and I'rofessions Cnde):
I � I,as ow�ner of fhe property,am exciusively contracting
wilh licensed mniraclors to construct U�e project
(Sectinn 70a4,Hucinesc and Profesxionx Code).
CONSTRUCTfON LI[tipINC.ACFNCY
I hereby affirm Ihat there is a constniction IenJing agency
for the per(nrmance nf thr work fur x�hich �his permit is
iseucd(Sec.3097,Q�.C.).
I.ender's 4am•
Lendcr's AJdrccs
1 certify ihat I havr rr;id this apC�ication anil st�ie that �he
abnve infnr 'on is rrect.1 agree to comply aith all County Sfili R1iVIiRSiC PUR fiXPLAN.aTORY LAYGUAGF.
orAin�nce and Stalc laws reFulating Plumbing, and hercUy
authrni�e pre tali es of this County to eMer upon the
above�mci ��d .rty for inspeclion purpo5e5. �/
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