HomeMy Public PortalAbout4839 ARDEN DR_Plumbing__ ION
r VKh that ISCO?APENSATate of consent to
76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I-hQrBby affirfi that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
ffP''ool'llIicy No. Company -
L_! Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGQ
ADDRESS
O 1� �
❑ Certified copy is filed with the county building inspection _
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant A�__3 WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATHTUB �� ASSESSOR
(This section need not be completed if the work involved by the
SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) OWNER �'z�
LAVATORY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to4' SINK /� MAIL
become subject to the Workers'Compensation Laws.
/ (! ADDRESS c•�-D �J' GL-
a,Zn ^ v J �, t DISWASHER CITY �� � A� CA C J TEL.NO.
Date PLIC Applicant �m�"�— CLOTHES WASHER ' �'—�"G_
NOTICE TO APPLICANT: If, after makingthis Certificate of CONTRACTOR
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR /Q (� � Oa
provisions of the Labor Code, you must forthwith comply with such ADDRESS 2.-� v K LV to
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION r B� CITY ��Q f y� TEL.NO. ?�j�(��
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 4Cj Q
(commencing with Section 7000)of Division 3 of the Business and STATE LIC.
Professions Code, and my license is in full force and effect.
GAS SYSTEM OUTLETS LICENSE NO. �'�'" CLASS C.
OUTLETS OVER
DISTRICT NO. PROCESSED BY
�� (�� C V•Z 5 PER SYSTEM �6 1
License Number Lic.Class D ,y a,- Qv I�
��vYf•+ FINAL / 6
DATE _�•Z VALIDATION W
b
Contractor —' `�'� " J Date fL
❑ FINAL Z
I am exempt under Sec. BY
BAP.C.for this reason 50
Date:
Plan check fee pop-
Signature
Signature
PLUMBING PERMIT ISSUING FEE$ 1"3. Q
❑ TOTAL FEE
SINGLE FAMILY Plan check applicant _
HOME OWNER-BUILDER DECLARATION Name ",
4
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Address
Code):
F-11,
Tel. No.
I, as owner of the property,will do the work and the structure
-t• j •-y .-n�»..
is not intended or offered for sale (Section 7044, Business ;P,; �_ �,.,� m 2_a�._.;f
and Professions Code). ,
CONSTRUCTION LENDING AGENCY
'•_• !! :I°�` ,it
I hereby affirm that there is a construction lending agency for the -
performance of the work for which this permit is issued (Sec. 3097,
Civ.CJ ^:rl `
_ =r Zor :;
Lender's Name - i
O lul
Lender's Address
I certify that I have read this application and state that the above ,
information is correct. I agree to comply with all County ordinances
and State laws regulating Plumbing, and hereby authorize
representatives of this County to enter upon the above-mentioned
property fpr-inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date