HomeMy WebLinkAbout1785A (224) i
`v°K"�xs'�°"'P�"SAT,°"°r`"LAR"T`°" """'". APPLICATION FOR PLU.MBING PERMIT
� i hereby afficm that [ have a certificate of consent to self c�s�v(z-eo� �
� insure,or a certificate o1 Workers'Compensation Insurance,or �
i a certiPied copy thereof(Sec.3800,Lab.C.) + �
� COUNTY OF LOS ANGELES BUILDfNG AND SAFETY
� Yolicy No. .Companp - .�L�� .
� � Certified copy is hereby f'urnished./ FOR APPLICANT TO FILL IN(PRINT OR TVPE) BUILD�NG l �
� � Cer[ified cn c filed with the count buildin fdUMBEFi FIXTURE OR ITEM � FEE ADDRESS ��� . �Y.,�pr,T
py�. y g inspectinn
department. LOCALITY ,/
WATER CLOSET • -LE� '/'�L'T+,.er �L�
Date Applicant NEAREST '
BATH TUB CROSS ST.
CfiRTII'1CATl Ob�F,XF:M17PTION FAOM WOIiKt:RS'
COMP}:NSATIUN 1NSURANCt; SHOWER OWNER ..g ��
(This section need not He completed if the work invotved LAVATORV qDDRESS .� � � �
by the permit is foc onc hundted dollazs (S100)ox IessJ — p
SINK CITY 7EL.NO3��,JnL�� U ,
I cer[ify[hat in the perTormance of[he work for which[his DISHWASHER �
permit is issued,I shall nnt employ any person in any manncr CONTRACTOR� ��,t.�, � > ��� G �' ,
so as to become subject to the Workers'Compensation Laws. CLOTNES WASHEF7 r F�
AD�RESS �� j ?S � 4�� L) .
Date Applicant _ SWIMMING POOL RECEPTOR �
N()TICE TO APPLICANT:If,after making[his Certificate of CITY����. � /' �,y`+r�y TEL.NO fY�-��'� �j .
lixemption, ynu should becume aubject t�� the Workers' LAWN SPRINKLERSYSTEM ��
Cnmpensation provisions of the Labor Code,y�u mus[f<xth- STATE � /( � LIC. m
wi[h cumply with such provisions or this permit xhall be :NATER HEATER syA LICENSE NO. ;�/.J f CLASS��=":�
leemed revoked. GAS SVSTEM OUTLETS i �ISTRICT NO. PROCESSED BV
LiCENSEDCONl'RACTORSDECLARATIUN OUTLETSOVER �`�� y:'�idt�.+�.d�.�
I hereby affirm th;�[1�m licensed under provisions u[Chapter 5 PER SVSTEM � �
9(commencing wi[h Soction 7000)uf'Division 3 of the Busi- FINAL �
ness and Professions CoJe,und my license is in full force and DATE `��Q�. VALIDATION �.
effcct. � �'
� � FINAL \
l.icanse Number=��� � Li�.Clijss�_�'� � gy �L���_ / , ,
r--
Contri�ctor Ua[e ' .
� [am ezempt from the ticensing requirements as i am u �f P�an eheck fee ���'
licensed archi[ect or a regis[ered professional engineer � pWMe1NG PERMIT ISSUING FEE$ "��t / � �
acting in my ptofcssional capacity (Section lOSI, Bus- ; . ° .j,
iness.md Profcssions Code). � <
y TOTAL FEE ��T SG� .
[,ic.or Reg.No. Date __ ? Plan check applicant ��� ;` i i g.�A ��
y — _
,��. Name � �
� F109�1R ON�NPR-BU[LDER llP,Ci,ARATIDN t _ .___________ �� �i e R � m e;j 3
{ Address
I hcreby affirm that [ s�m ezempt from the Cuntractor's � �,� �- "
l.icense La�v fur[he fol�owitt�teason(Section 7031.5,Susi- � City Tel.No. � p c i ��"�`
ness ea�Professions Cnde):
� f� m � <, I ?.5'v"'e
[,3s owner of tLe property,am exclueively cvntracting �[
with licenseil cpnErar.tors to cons[ruct thc project ! n �
' (Section 7044,Eusiness and Yrofcssions Code). �� E�tl Y'—�2
CONSTRJCTION LP:NDINC AGENCY �? ���
I hereby affitm thxt there is a conxtruction lending agency !
for the pertormance of[he work fur which this permit is y �
issued(Sec.3099,Civ,C.).
Lender's Nama
�
Lender's Address �
I certify that I have read this application unJ state tha[ the +�
above informa[ion is correct.I agree to comply with ull County ' SEH RHV BRSFi(�OR iiXPI.ANATORY LANUUAGE
nrdinance.s and State laws reKulating Plumbing, and hereby �'
autliorize ropresenta�tives of this County to enter upon the �
�nbove-mentiuned property for inspection purposes. �+
(
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Signa[urc uC Permittee Date ,a -
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