HomeMy Public PortalAbout9549 BISBY ST_Plumbing__ WibRICERS'COMPFNSATI°" DEC,' "°" APPLICATION FOR PLUMBING PERMIT
I HSreby affirm that I have a certificate of consent to self 76A667A
Insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
r
Or a certiflood copyth)efech(Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
ompany
❑ Certified copy Is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BU ILDI NG
Certified copy is filed with the county building Inspec- ADS
ton department. NUMBER FIXTURE OR[TEM O FEE wx
LC)G41f��
Dat Appllrpnt WATER CLOSET NEAREST
CERTIFICATE OF hDTAPTI FROM RKERS' BATH TUB CROSS
COlMPENSAT10N INSURANCE %%OWER OWrER
(This section need not be completed If the rwo,*limohred by
MAIL
th1 permit Is for one hundred dless
o4ats(=1010}or .) LAVATORY ,p{ ESS95-44
I certify that In the performance of the work for which this
permit Is Issued, I shall not employ any pemgn In any manner SINK TY
EmvL—CL -4
so as to become subject to 1118 Worker ComPensat[gn Laws. DLSHWASFER
CONTRACT
pate Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certlficate of SWMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' 7
Compensation provisions 6f the Labor Code, you must forth- LAWN SPR It4a-ER SYSTEM L
with comply with such provisions or this permit shall be STATE Lr—
deemed
Cdeemed revoked. WATER HEATER LKIEN:SE NO. 0 CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT BY
hereby I affirm that I am licensed under provlslons of Chapter 9 ' OUTLETS .
}
(commencing with Section 7000) of Division 3 of the BusJne= 5 S� DAA r� VA DATI N 0004V
dnti d Professions Code,and my Il4enae In full farce ff
eect, FINAL
License Number tic. Clash O!
ContraciorBYG
F-1I am exempt under c.Se1 �r s � CZE
L �
B.BP.C. fak,this reason Plan check fee �'1 1 2 3'A Z
-
PLUMBING PERMIT ISSUING FEE;
Signatur1 3 Q 5 0
TOTAL FEE
Plan check applicant
0 0 0
SINGLE FAMILY .( 1.2
Q y�Q
i-IOME OWNER-BUILDER DECLARATION Name SSS 44
I hereby affirm that I am exempt from the Contractors License Address
Law for the following reason (Section 7031.5, Business and
Profession$Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
structure Is not Intended or offered for sale (Section ,
7044, BusInonnnd Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction leniling agency for
the performance of the work for which this permit Is Issued
(Set. 3097, Cl v. C.)
Lenders Name
Lenders g¢dress '
I certify that I have read this applicatlon 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-men I for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
g azure ol Permittee Date .