HomeMy WebLinkAbout1746A �SATION➢ECLARAT.J� ]�AfNA �'I
.,��C a certiCicate oe�o�,�,t to sr�P ceev(z-so) .RPPLI�ATION FOR PLUMBING PERMIT
�v�� - � ,,vf Workers'f;omPensation[nsuranc,e.Rr . . � . ._. .. . . . . . �.� , . . . � .
� . . reof(Scc.3800,Lab.CJ . ' . ' . ' . .. - . '
,�`�'� �f' ���� COUNTV OF LOS ANCaELES + BUILDtNG AND SAFETY I
. , ComPanYj. G�_..�_
I � a.ertified copy is hereby furnished. FOR APP�ICANT TQ FILL 4N(PFINT OR TYPE) BUILDING
ADDRESS 1/ +
� CertiP�ed copy�filed wiEh t county b�jilding irtspection NUMBER FIXTURE OR tTEM • FEE �
Dat��Aeparttne � �j/ „�, WpTER CLOSET LOCALITY
Apylicant �������Y�a"� NEAREST
BATIi TU8 CROSS ST. - �
CERT[FICA7E OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE SHOWER OWNEH ��
LAVATORY MA�� } I
fThis section need not be completed if the wotk invotved aooaES fo�.��� a �
by Aie permit is foi one hundced doltuc(5100)ox less.) SINK CITY TEL.NO.��j V j
I certity fhaf in the performance oF the work for which this DISHWASHER � �
permit is issund,1 shall not employ any person in uny manner CONTHACTOH
so as to bewme sub}eet to the Workers'Cnmpertsation Lews. CLOTHES WASHER iy E �
ADOHESS `
�ate Appiicant �B «� V !
SWIMMING POOL RECEPTOR •� W
NOTiCE 70 APPLICANT:[f,affet making this Certificate of � CITV TEL.NO��— �7� y ;
ExempBon, you shoukd become subject to the Workers' LAWN SPRINKLER SY5TEM STATE ^� U0. z �
Compensatian provigione of the Eabor Code,you must forth- yyqFER HEAFER LICENSE NO.��J�C_J CLASS
with comply wi[h auch provisiuns or this permit ahall be ��� �
deemed revoked. DISTRICT NO. PROCESSED BY ;
f GAS SYSTEM OUTLETS n� �
L[CENSED WNTRACTORS DECLARASION OUTLETS OVER � �d y�r.t�� �
I hereby effirm that!am licensed under prnvisions of Chapter 6 PER SYSTEM
9 (commencing with Section 7000)o[Division 3 0€the Busi- FINAL �
ness and Profasions Code,and my license is in fuli.force and '� '�� DATE VALIDATION �
effect.
�] I
License Number�✓`Q� Lic.Gass ��� F�NAL . �
/n. E�;}�, �/ BY �
Contractor%y��',�c�� �����uT � /o n-�p� �
� Pian check fee ��'. . G`� ' Jt�
1 am exempt from the licensing requirements as f am a l/ �
licensed srcAitect or a Eegistered profess�ona4 engineer p�UMBING PERMIT ISSUING FEE$ �' � Gl(,PV""� i
acti�g in my professional capacity (Section 7051, 8us- f� � v-�- b
iness and�Nrofessions Code). �� F
TOTAL FEE �
E.ic.ur Reg.No. Date plan check applicant ���' . - �
�_i i e:6 p �
HOME OWNER-BU(LDER DECLARATION Name � j�p5� �p o � . r i
1 hereby afC�rm that I am exempt frum the Contractor's Aaaress n` �jJ'� • � f
License Law for the followin reason Section 7031.5,Busi- `- � �� ''-�'��U
g � City Tel.No.
ness and Professions Code): « V�,�,,v;.,,1:
� I,as owner ot the pcoperty,am exclusively contracting �� "
with ticensed contractors to construct the project . �;�L j_S%(i
(Section 9044,Business and ProCessians Code).
CONSTRUCTWN LENDING AGENCY �
I hareby afflrm that there is a construction lending agency
for the performance of the work For which this permit is ,
issued(Sec.3097,Civ.CJ. � �
j
Lender's Name
-'s Address �
�t I have read thix applicatlon and state that ihr -
'�n is correct.f agree to comply with all County � SEE REVERSE FOR EXPLANATORY LANGUAGE
'!te laws-regulating Plumbing, and he�eby
'��es of this Caunty to enter upon thc � �
•for inapection purposes. ' -
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llate .
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