HomeMy Public PortalAbout9014 ACASO DR_Plumbing_7/3/1990_heater, tub, lavatory .A`?r'WOFi#tER'S COMPENSATION-DECLARATION 20.0026 DPW 9/89
I hereby affirm that I.have'a Mtnflcat of consent to-self insure, 76A667A APPL''ICATIOWFOR PLUMBING_ PERMIT- 11
or a certificate of Worker's Compensation Insurance, ora certified 4 ,
copy thereof(Sec 3800 Lali C) 1 „j'• .�' • +• =.• t' • ' + •. . '
COUNTY OF'LOS•ANGELES• DEPT:OF PUBLIC WORKS_ DEBT.OF PUBLIC WORKS DIV.
Policy No Company 4 nha T AJ
Certified copy is hereby furnished• BUILDING
❑ r FOR`APPL'ICANT TO FILL IN(PRINT OR TYPE)
'Certified copy is filed with'the county+building inspection r ADDRESS Ort 8 17R ;
,department r ,I NUMBER FIXTURE OR ITEM, f FEE',
LOCALITY
r Date 7 • -y.Applicaint .TG7 �1!/�i��. WATER CLOSETNEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB- 1. CROSS ST + 1' a • ;'
'
COMPENSATION INSURANCE. • ASSESSOR
((This section need not be completed if the work involved-by the SHOWER r' ' 3" MAP BOOK Y PAGE PARCEL+
permit is for one Hundred dollars($100)or less.) ! LAVATORY OWNERr `�Gt�o�l ,+,T7�15,v
certify that inrthe performance of the work for which this permit
is issued, I shall not em to an MAIL
p y y person in any manner so as to SINK _ , r ADDRESS 7rj2• l� t Ay/�.
fbecome subject to the Workers'Compensation Laws _ -• �, • � .
t DISWASHER 'CITY �4/ G TEL'NO ;
Date 7{ 9� Applicarit -Z~1w iy_VyA,W- - CLOTHES WASHER a CONTRACTOR
NOTICE TO'�APPLICANT-'If, after making thus Certificate of. .
,'Exemption,you should become-subject to the Workers'Compensation SWIMMING POOL RECEPTOR
°proynsnon`s of the Leborf'C' , you must forthwith comply✓wnth such ADDRESS'' r
provisions or,this permit shall be deemed revoked L:WN SPRINKLER SYSTEM i �d GVQ l r� 1/
LICENSED CONTRACTORS DECLARATION CITYTEL NO qq a
s r '
I hereby"affirm that I am-Incensed-under provisions of Chapter`9 WATER HEATER ' STATE LIC
(commencing wrath Section 7000)of bnvnsion'3 of the Business and GAS SYSTEM OUTLETS LICENSE NO >�J"Z �i27 CLASS
Professions Code,and my license is in full force and effect -
f
CE BY
OUTLETS OVERCu$TAIV
��j `
5 PER SYSTEM �(r,J1 ({�( O
License Number ✓F27 Z5 Lic Class g • ' I , f
n ` FINAL
DATE V 7- 9Zj V LIDATION G W
'7HNr/1AY Date -
Contrabtor - dr
' I amexempt under Sec r FINALf% /v pyo Z
B&P C_for this reason
Date
Plan check fee n
< _ _ '' •
r, PLUMBING PERMIT ISSUING FEE$• '
Signature
❑. TOTAL FEE
` Plan check applicant t' Z /
SINGLE FAMILY
" `HOME OWNER-BUILDER DECLARATION ^ Name - f �" r _.� r1C ;ay
I'hereby affirm that I am exempt from the Contractor's License Law . •_ ° °
for the following-reason(Sectidn 7031 5, Business and Professions Address 7? 7- < ■Ct1 `�)
Code) � � �t, City .., � Tel No ' Z• - � ..i.r � ITEMS
❑ '',I,as owner of the property,will db the work and the structure i 4 f' �
is not intended or offered for sale(Section 7044, Business k _ , 1.)TAL ' �s 519
and-Professions Code) 1 + : `�* , ,- s• , �• 'yy r
-CONSTRUCTION LENDING AGENCY , F - - ' _ *' ) Cf'! y,`lam,■SIJ
• c t/''.��t��t{At,tr�❑❑ t
I hereby affirm that there is a,construction'lending,agency for the , - ;" 4FlF1G r; � )
\performance of the work,for which this permit ns-issued(Sec 3097;
Lender's Name 13000-0001 , 7/,'31/51)
r - - - r kt G •.
r Lender's Address '' • 163
` _ t At 1,8 ,fig 1 T
I certify that I have read this application"and state that the above x
nnformatnon;is correct I agree to comply with all County ordinances r r poll.- - _ (•
and'State laws regulating�Plumbing, and hereby authorize +" - } '•' +. ' `"
representatives of this County to enter upon the above-mentnonea'
property for inspection purposes SEE REVERSE FOR EXPLANATORY,-LANGUAGE` r ✓