HomeMy WebLinkAbout0803A '"°RKERS•`°"'PE"SAT'°"°E"AR"T'°" APPLICATION FOR PLUMBING PERMIT
I h�reby,o4firm thot I have o ce.��ficofe oi consent io self in- pA��A PW 4�87 �
sufe,ar a cettificole of Workers'Compensalion Insuronce,or o CE 817(REV.B/[i6) �
ceriified copy ihereof(Sea 3800,Lab.C.) � •� �
Porcy No.73WC00504�p,�6hyNATIONWIDE C�UNTY OF LOS ANGELES DEPT.OF PUBLIC WORI�S �
� Ceriified copy is hereby fumished. � � � `
F02 AP?LICANT TO FILL IN�PRINT OR 1YPE) BUILDIN
(� Cer�ified copy is iiled with the county building inspection noortES 2� SOUTH SUNNYHILL PLACE
�—�l �pUriment. NUMBER FI%TURE OR ITEM (d FEE �OCALITV
Da1e4-1—HH ,aPPu�o�iNEW PLUMBING 3 WATERCLOSETITOIIET) ( LH NEAREST - , �
CERTIPICATE OF EXEMPTION FROM WORKERS' 2 � BnTH iuB 1 Z CROSS ST. � -
COMPENSATION WSURANCE SHOWER OWNER '
(Thit t�Nion nNd not b�completed i(th�work tnrolv�d by �i�
th�p��mll i�for on�hundnd dollan(3100)or bsa.) �AVATORV nODae55 1 AIRWAY AVE. ITE N
1 cerrify thaf in Ihe performonce of Ihe work for which fhis per-
mi�is issued,I shall not employ any persan in any manner so 2 SiNK 1z CiTv $,1,� TEL ND. _
as to become s�bjeU�o the Workers'Compensalian Laws. DISHWASHER
CONTRACTO W PLJJM�.IN��QHTI�.
Da1e � Appli[ant � CIOTHES WASHER 6 AD�RESS
NOTICE TO APPLICANT:li,after making Ihis Certifica�e of EK- Syy��iNG POOL RECEPiOR
emption,you should become subject lo Ihe Workerz'Compen- [iTV TEL.NO.
Sotion provisions of Ihe Lobor Code,you musf forthwilh comp- LAWN SPRINKLER SYSTEM —
ly with such p.ovisions or this permil shall 6e deemed revok- STATE LiC.
ed. 1 WA7ER HEATER 6 LICENSE NO. C1A55 _
LICENSED CONTRACTORS DECIARATION DIS7RIQ ND. PROCESSED BV
I hereby offirm thal I om licensed Vnder provisions of Chopter GAS SVSTEM OUTLETS /�
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
fe d Professions Cade,and my license is in lull force and ef- 5 PER SYSTEM FINAL V LIDATION a
DATE .Z(�•� O
Lkense Number 426109 Lic.Class G-36
U
FINAL
Contracro� NEW PLlTMSING Dare 5-31-88 ev Cy.l�` p
� I om e.empl under Sec. V
W
t B.BP.C.for�his reoson pion CheCk fee � Z
Do�e: PLUMBING PERMIT ISSUING FEE S
Signature ' TOTAL FEE •=G 8�J�
SINGLE FAMILY LOH OO
HOME OWNER-BUIIDER DECIARATION Plon check applimnt �i • • • • •J
I h?re6y cfii�m thet I em exempt frem the Contredcr's License Nnme ( • 1 ll e]U l%
Law 1or 1he(ollowing reason(Sectian 7031.5, Business nnd
Professions Code): � Address . o � ���1 J��?�
� I,os owner of the property,will do the work ond the City . Tel.No. O E.� � —O H
srrocWre u not intended or oifered far sale(Section 70d4, .
Business ond Professions Code). � �
CONSTRUCTION IENDING AGENCY
I hereby offirm thot there is o cons+ru<rion lending agency for �
�he performance of�he work fo�which ihis permil is issued . .
�Sec.�09I,Civ.C.). . � -
Lender's Nome
lender's Address t �
I certify thot I have read ihis applica�ion ond slale�hal�he .
o6ave informatian is co�ract.I agree to comply with oll County . ,
ordinances ond Slate laws regulating Plumbing,and hereby ,
outhorize representa�ives of th�s Coun�y�o enter upon the '
o ve�me tioned property lor inspeclion purposes. �
���� .�7 SEE REVERSE FOR EXPLANATORY LANGUAGE
SignaWre of Permit�ee Da�e .
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