HomeMy WebLinkAbout1325A �vUH�$�C��FIV.��n�.��.�./1k/1���nN J6A66)A
, �,e�r�,Y affirm �h�t � h��e ��r�t;�«ate of��nstnt t�5��e CEB�]�2-80) APPLICATfON FOR PLUMBING PERMIT
insure,or a certificxte ot Workees'Cumpeusation lnsurnnee,or � � � �
a certified cuP}•thereof(Ssa 3800,Lab.C.) � � �
� P �.�� COUNTY OF LOS ANGELES BUI LDING AND SAFETY
Poucy No. com nny , . ..
� Ccrtified copy is hereby furnished. FOR APPLICANT TD FI�L IN(PRINT OR TYPE) BUILDING ( �� �1��_„, _tlOp G \ �
AD�RESS '1�K-{N �•-�
�'er[ifie�copy is filed with fhe cDUnty b�u71ldL�g inspeCtion NUMBER FIXTURE OR ITEM � FEE " `
Date�epartme //f.//_ WqTER CLOSET LOCALITV ���o�� ��/
:1pp�icanl___���r��r� NEAREST \ - _ .
L, BATH TU8 CROSS ST. QV�-� l S U yyyvf'�� �
CLR'fIf�ICATE OP EXEh]YTION RO_ OKKERS' - -
C:Oh1NL'NSATION INSURANCL SHOWER OWNER G�� G�r�`�
LAVATORY MAIL
(This section need not be completcd if the wock involved q�oRess__�_�`�l� � ��(L��p p a
by the pecmit is for one hundred dollazs (5100) ox lessJ � � -�—� �
SINK — CITV �1 p��'�� TEL.NO�j�'4"�'Z�, �CJ
i certify Yhat in the performance of the work for which[hix DISHWASHER --�p � (� U
permit is issued,I shalt noi employ any person in anp mmmer _— ---_ ___._ CONTRACTOR � `�
� r-C11�_ ��—.-.5+
so as to become subject t�the\Vorkers'C'��mpensation[aws. CLOTHES WASHER ADDRESS ���� tU�'`�"�^ U
Uute _Applicant_ � - � ��,
SWIMMING POOL RECEPTOR
NOTICI 1'U APYLICANY:[f,aftee making this Certificate of ---- I ^a� CITY � ��'� TEL NO.��j�� If%)
l�:zemption, you shoulp become subject to the Workers' LAWN SPRINKLER SYSTEM � I STATE s, UC. / 2
�Compensation provisions of the Labor Code,you must for[h- — LICENSE NO.� � �V Z' C�ASS l.i� ��
�vith com�ly with sucii rr�visions ur [his permit shall be WATER HEATER
deemed revoked. I ,/� � DISTRICT NO. PROCESSED BY
GAS SYSTEM OUTLETS �
L[CENSED CONTRACTORS DEC[.ARATION OUTLETS OVER LC /��
. Ck�-zX-'t-'
1 herehy utf'irm th¢it I um ticenscd w�dur pruvisions of Chapter 5 PE R SYSTEM -
9 (commenaing with Section 7000)of Uivisian 3 of the Busi- • • /� FINAL �{
ness.�nd Yrofessions Code,and my license is in full force and �-7-Q �e L7-'G'�' DATE i �y��'� VALIDATION
ef£eci.
� FINAL F�
L��ense tiumhEr, �QS^r— I,ic.Cinsn C-�S gy �,1�1`�Ly,t),9�
C�ntracto�,e,.�r_ �At��.� Date p}'�-Z��- � � �
� 1 am exempt from the Iicensing requirements as i am a Plan eheck fee ___
liCensed arekietect ur a fegi5teret( �rofessiunal engineef pLUM81NG PERMIT ISSIJING FEE$ �'�'
acting in my professional cupncity (5ectinn 7051,Bus� — .�t•'
iness:incl PrnCessions Code). TOTAL FEE �S ��)
Lic.ur Rng.No. Uate _ Plan check applicanc j� _
IIOh1l 01VNER-DUII,UIiR iN?CI,ARA'C[ON � Name ���� � r��� "�, `5 L,^�'
Address 7 �, • o u S
I hercl>y affirm thut I um ezemp[ from the Conlructur's ,�`� ��� � �+'�
License Law for the following reason {Section 7031.5, Busi- City ���.,ry.p Tel.No.L�S'yZG,L 1 m +'��v ij
ness and Professions Code):
� I,ae owner of the property,am exclusively contracting " '� °^L'���U c:
with licensed contrac[ors to construct the projec[
(Section 7044,Business and Professions Codc). C I,C���5 C
CONS1'RUL'TION LRNDING ACENCY �
I hereby affi�m that there is a conslruction iending agency
-fot Yhe perfurmai�ce of the w rk for a+rhicS this permit is � ��
issued(Sec.3097.Civ.C.). '
Lentler's Naine _ �
LenAer's Address _
t certify that 1 hUve read this npplicution vnd s[iite thut Yhe
above informution is correct.1 ugree to comply wi[h ail qounty SEE REVERSE FOR EXPGANA'PORY LANGUAGE
ordinances and S[ate laws regulating Ylumhing, und hcrchy
au[hori c mpreseniatives of'this County tu enter upon tlie
pbove-�entinned property for inspection purposes.
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