HomeMy Public PortalAbout9557 BISBY ST_Plumbing__ �r"°R' sChaveaSAT-°"DEC`,�sont :20..�DPW,4/e7 APPLICATION FOR PLUMBING PERMIT
��klerb y �fflrm that I TION
have a certlflcate 6f consent to self in- 7�7A
surq,or aIterilflcate of Workers'£Compensatlon Insurance,or a CE 817(may, 8/86).,
cgftlfled copy thereof (Sec. 3800, Lab, C.)
Policy No, mpany COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Co
Certlfled copy Is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
dbrt rted opy Is flied wlththe couaty bulldln¢Inspection NUMBER FIXTURE OR fTEM fEEq ' AIVADDRESS
LCCALrry
WATER dOS T(TO14,r).
Date ^Apel leant NEAP
CROSS ST, T.
CF,RTIFICATE OF EXEMPTION KROM WORKERS,
PATH�B•
COMPENSATION INSURANCE OWNI=R �p e rt
'(Thls soctlort ni*d ti&t be comWed If th•Work I olwd by MAIL ,
th• permit Is for one hundred dollars ($100) or less.) i_AVATbRY ADDRESS l
I certify thatin the performance of the work for whrch this per-
m-ifCITY Is Issued-, I shall not employ any person Irl ohy manner toIC
as to become&*ect to the,WorkoW Compensation Laws: DISHWASHER
CONTRACTOR
Date_ App[leant C10THES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ExIna
-
emptton,you,skould become sub act to the Workers'Compen- SWMMING POOL RECEPTOR -
CTTY TFL i NO.
urtlon provlslons;bf the Labor Code,you must forthwl'th comb- LAWN SPRINKLERSYSTEM
Jy with such provlslons or this permit shall be deemed,revok- STATE JIG
ed.' WAFER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS D�-AR.4TION DISTRICT BY
I horebyafflrm that!am licensed un erpro,vlslpns of•Chopter GA�,SYWEM OUTLE-M
9.(coramencIng with Section 70Q0)of DIvlslgn3 of the Business OUTLETS OVER
and Professions Code, and my license Is In full force and of- 5 PER SYSTEM FINAL V I ATJON
fact. ' I DATE
Llcenie Number Llc. Claaa - V
F I NAL
{C�oontractor Ddte BY
L ] A F LU
I am exempt under Sec. .
W
B,BP.C. for this reason Plan check fee $8 Z 5 A
Date: PLUMBIN, PLRMIT ISSUING FEE;
Signature # o o a 0 0 5
TOTAL FEE
SINGLE FAMILY Plate check dPP Inl ` • • 2250
HOME OWNER-BUILDER DECLARA ION lcao 0 0 22506
f hereby affirm that I am exempt from the Contractor's LkMnse Noma
taw for the fo-Howing reason (Sectlon 7031.5, Business and
Professions Code)' Address 0 1,29-88
f, as owner of the-property, wHl do the work and the City Tel, No.
structurd Is not Intended or offered for sale(Section 7044,
BUslriess and Profenions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for
the performonce of the work for which this permit Is Issued
(Sec. 3097, Clv.C).
Lender's Name ;
Lender's Address
I coolfy that I have read this application and state that thq
above lhformatlon Is correct. I agree to comply-with all County ►
ordinances and State laws regulgting Plumbing, and hereby
authorize representatives of this County to enter upon the
abov entloned pr for I ion Purpose.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sfghaturd of Per Date
)