HomeMy WebLinkAbout1601A ._— , �,
'� WORKERS'i:OMPEN3A'LIONDECLARA'CION iGA6��A � I
,Aereby affirm ,he� � �eve a��«E�,��ete of�a��t to se�E «.,,��-.o, APP,LICATION FOR PLJNiBING PERMIT
��sure,or u certificatn of Wurkers'Compensation tnsurance,or . ...- . .. - � � - - � � �"
cerNfi d copy thereoP(Sec.3800,Leb.CJ � ' ' , �
w��y-a9G 5%5 ./ � COUNTY OF LOS ANGELES BUILOING AND SAFETY
� Policy No. Company�,�r��_�'� .
I � Certified copy is hereby fumished. FOR APPLIGANT TO FILL IN IPRINT OR TYPEI BUILDING�//� p.�.ff,n�, ����
`,.,,C ADDRESS ��� J�`��
/`�`�I Certified copy ic fled with the cnunty buildi g inspection NUMBER FIXTURE OH YfEM • FEE ,
/ �-eQa�� WATER CLOSET LOCALfTY�" �
➢ate ✓ � ADP��cant NEAREST / AA�p�,/
BATH T116 CROSS ST. � ��G�!�/!!��✓ !
CERYlF[CATE OF EXEMP'FION FROM WORKEkS'
COMPENSATIOPi INSllRANC6 SHOWER OWNER /���yd`(/�'1�
LAVATORY MAIL 6�,,��/� I
(This secdon need not be completed if the wock{6VU�YEJ qooRESS 7G'J'G°7C? �
6y the pennit is foc one hundred Jollazs(SI00)or tess.) SINK }
GITY� TEL.NO. O 1
1 certify that in the performance of the work for which this DISHwASHER U '
permit is i&sued,[ahall�ot emplay any person in any manner CONTHACTOq
so as to become su6ject to the Workers'ComDensation Laws. CLOTHES WASHER ����/,7 ' �
AD�HESS O
Date Appiicant T�� V—
SWIMMING POOL RECEPTOR
NOTICE 1'O APYLICANT:tf,after making this Certificate uf dTY � 7E1.NO. W
Ezemption, you shou{J become suhject ta the Workers' LAriNSPRINICLER5Y5TEM ��//'� /� 6.
Compensation provislons of the Labor Code,you must forth- �ICENSE N0.`V'V ' �L CIASSFI'' Z
with comply with such provisions or this permit shall 6e WA7ER HEATER 9 �
deemed revoked. GAS SVSFEM OUTIETS ` �/� DISTRICT NO. PROCES3ED BY
LICENSED CONTRACTURS DECLARATION L� �'7
OUTIETS OVER f`� R����/
1 hereby afP¢m that 1 am licensed under provisions of Chapter 5 PER SVSTEM �
� 9 (commencing with Sectiun 7000)ot Division 3 of the Busi- FINAL '
aess an�1 i'roCessinns Code,and my[icense is in futl Torce and c� d��� QATE � /pZ �a VALIDATION (
effect. � �
r, � � '�/ PINAL
License Numbr� Lia Clasa . gY
ContraCto/Y�-Y� Date �I���D
� 1 am exempt from the licensing requirements as 1 am a Plart check fee �
licensed architcct or a rtgistered professional engineer pLUMe1NG PERMIT ISSUING FEE$ � �
acting in my proCessionel eapacity (Section 705t,6ur �
iness and Profe6sions Code). TOTAL FEE ,� � �
Lic,or Reg.No. Date Plan c�eck applicant ! /
/%f�•
HOME OWNER-BUILDER AECLARATION Name � �
I hereAy affam that 1 xm exempt Prom the Contractor's Address
I,icense Law For the toilowing reason(S2ctiun 7031.5, Busi- City Tal.No.
ness and Protessions Code): �
� t,as ownet of the property,am exclusively contracting
with licensed rorttrac[ors to conslruct the projeet
(Section 7D44,Business and Professions Code).
CONSTRUCI'ION LENDING AGENCY �
1 hereby affirm that tbere is a construction lending agency t
�� �Q.� ht
for the performance of the work for which this permit is �
issued(Sec.3097,Civ.C-)./1/�- '
Lender's Name �-���� f'� � � � �" �
Lender's Address � • • � .:,�� �
�
I certify that [have read this application and state that Ihe • c c� ?,Ct J�
above information is correc[.I agree to cort�ply with aIl County SEE REVERSE FOR EXPLANpTORY LANGUACE
ordinances and Stata laws mgulxting Plumbing, and hereby (�� � j�..�C
authorize representatives of this County to enter upon ihe
above-me �oned prop ty for inspection purposes. -
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