HomeMy WebLinkAbout1345A ��okKFHs•��.�f�I:�S.aTinVDFCLARATIOV ��•••�• APPLICATION FOR PLUMBiNG PERMIT
I I hereby atfirm that 1 ha��e a certificate of cnnsenl to sclf �c���(�-aal �
� inxure,or a certificare n(N'nrkers'Compensalion lnsurancc,or
� n certif�ed copy iherenf(.Sec.7800,Lab.C.
� �; zc���� COUNTY OF lOS ANGELES BUILDINO AND SAFETY
"� Po!1 c N Com any.
1 y °'c�/�'�O,�r
� � Cerfifie c�p��S ereF>•�urnishe:f. FOR APPLICANT TO FILL IN(PRINT OR TVPE) BUILDING / I
I � N U M O E R F I X T U R E O R I T E M • F E E AODRESS�(D v�E=P lP 5
CertiPied cnpy is filed with thr county huilding inxpe[tinn
Date�� � �' Q � WATEfiCLOSET LOCAUTV ���,�,�ON
ApD���ant ��� NEARE T
BATH TUB CROSS ST.
CF.RTIFICATE OF F.%F[MYTIO!+FROM R'ONRFRS'
COMPE�S.4TI041N:SURA4CIi SHOWER OWNER �� �� JQyI� C
E�'
MAI L �T
(This section need not fie compleled i(the wOrk involvW LAVATORV I qDDRESS .�IE'(� Y p}.
by the ptrmit is for one hundrcd dolluc(f100)or less.) SINK I ci7v 1� TEL.NO. z� �
1 rrrtif5'Ihat in the perfnrmance of ihe uvork fnr w�hich this DISHWASHER L O
permit i5 issued,I shall nnt emp���y any person In any manncr CONTRACTOR J
sn as to become wb)ect tu the Workers'Cumpensalion L����s. CLOTHES N�ASHER I !, U
ADDRESS
nate �,�25-YL .lpplicant SWIMMING POOL RECEPTOR � W �
NOTICE TO AYV�.IC.�NT:If,aftcr making thie Cenificarc nf CITY . TEL.NO. ( . I y
}:xempti�n, y�u should 6ecnme subject to tl�r Wurkers' LAWNSPHINKLERSVSTEM I gTATE LIC. /� Z
Cnmpensalion provisions nf the Labor Cnde,ynu must forih- yyqTER HEA7ER UCENSE NO. � �� CLASS l.�
w�ilh comO�Y ���tl� .uch D��visinns or this permit shall bc �ISTRICTNO. BROCESSEDBV
Jcemed revoked. GAS SYSTEM OUTLETS I 1Ci / ,
I.ICENSfUCONTR.4CTON5I1F.CI.ARATION OUTLETSOVER �(� L� :•�yc��, �
1 herehy affirm that I am Iicensed under prnvixions�.if Cheptcr 5 PER SVSTEM
9 (commencinR w�ith Srction 7000)of Di.�isiun 7 of the Rusi• �n DA E` pr�
nesa and Prnfessions CnJe,and mY license is in tull force and �+ ,� Q o4.. V � I�N
�ffe«. • Z,��? �
yp��,��(� 3/' FINAL
Licrn.0 NumFer4l�J�J`--'U— Lic.Cless��' b BV
C�niractor �'� nate �'2'S'��
I � !am exempt from tl�e licenaing requiremrnts as 1 am a P�a1?chCCk fee
IiceneeJ architect cx a registered professionel engineer pLUM81NG YERMIT ISSVING FEE S `�D
acfing in my O���csaaml capacily(Section 7051, Bux•
iness and Yrofessionc Cnde). TOTAL FEE l �fJ
I.ic.nr Re�[.N�. [)atr Plen check applicant
HOMIi ON'NtiR.BUII.UF.R UFC[.ARATION N�ma
�
� 1 herebl' �«��m that I am rxrmpt Gom the Contractnr's A�����
Li:er,xc L�u for ILt (uliowing rr�son (Section 70J1.5,Buai- City Ta�.No.
) ncu and profcscinns Codc):
i � 1,u nw�ner of lhe pruperty,am rzclusively conirecting �� 3 d,,Fl
' wilh iicenced contractnrs to construct thr project
� (Srction 703a,Pusinrss and Professinns CoJe). r• • • • •eJ
� CONSTRUCTIOV 1,ENDING A(iI:�CY � • • � 7 5 O
1 hereby affirm thnt there is a conctruclion lending a�ency
� for the perfurmence of the work for which this prrmil is
• • • 12JCa
I isaued(Stt.3097.Civ.C.). �
I Lender's Name O �,�7��•L
i
� LenJer's Address
I I certify that 1 ha��r read tl�is appiicalion ond state Ihat ihe
aboce infurmation ic rnrrecl.I aeree to comply aith all Counry SF.g RF.VF.RSF.POR EXPLANATORY LANGUAfF.
orAinancex and Statc laws re`ulating Nlumbing, and hereby
au�horite ropr senlatives o(this County to enter upon thc
ahoeame tio d properly!or inspection purpases.
i /' /Z.
I S'na[ rr of rmillee 1)ate
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