HomeMy Public PortalAbout9330 BROADWAY_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �Y
n� rlhere¢y affirm tI 4*1 have,. certificate of consent to self 76A667A
insure, or a certificate of Worker; Compensation Insurance, CE 817(REV. 10/81) T
or a certifiedi9-copy thereogf (Sec. 3800, L b. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N . /S' '0 __1. any
Certified copy is hereby furnis ed.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
kr Certified copy is filed with the aunty buildinginspeo- ADDRESS 933,0
B.toAZle��
NUMBER FIXTURE OR ITEM r FEE
ti�deprt C+�WATER CLOSET LOCALITY 7-�DateAppliSon NEAREST EXEMPT N FROM ORKERS' BATH TUB CROSS ST. '
COMPENSATION INSURA E OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
nE
I certify that in the performance of the work for which this ADDRESS
permit is issued, I shall not employ any person in any manner SINK CITYr, TEL. NO.0° 7-%5
so as to become subject to the Workers'Compensation Laws. DISHWASHER C-.I�r /)_ _f
CONTRACTOR f—/V
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of /02,0
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL. NO�>'/ Z
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM
STATE C.
4143 SZ CLA55
deemed revoked. WATER HEATER LICENSE NO.
LICENSED CONTRACTORS DECLARATION DI CT Nk P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER s V//Uy
and Professions Code,and my license is in full force and effect. 5 PER SY M FINAL DATE VA DATION V
_
License Number��'1/3,SZ Lic. Class // ti
ff � FINAL
O
Contractor Date� � BY
❑ U
am exempt under Sec. d
H
B.BP.C. for this reason Date: Plan Check fee D ( Z
PLUMBING PERMIT ISSUING FEE$ ISO
Signature lo / / [/ Lf•�
TOTAL FEE (�/Y`�,
Plan check applicant
SINGLE FAMILY 1 Q 5 A
HOME OWNER-BUILDER DECLARATION Name /
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and Address /) # e e e a e 5
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the I e o 30.50
structure is not intended or offered for sale (Section
7044, Business and Professions Code). e o e 3 0,5 0 6
CONSTRUCTION LENDING AGENCY I 9 i H 5
I hereby affirm that there is a construction lending agency for Q 0
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Nome
Lender's Address
I certify that I have read this application and state that the D
above information is correct. I agree to comply with all County
ordinances and Stat a s regulating Plumbing, and hereby
authorize represe ati s of this County to enter upon the
above-m nti a pr erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
id 4 Itu�-
Signatu ermittee Date
76A667-CE8 V 3-59
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
9rv11
BUILDING AND SAFETY DIVISION BUILDING
CAWJOHN A. LAMBIE. County Engin.,r ADDRESS _ _�z / hLL.
D. GRIFFIN, Sup t of Building -
LOCALIiY Y' '
FOR APPLICANT TO FILL IN NAE 5T.
NUMBER FIXTURE OR ITEM OWNER
v WATER CLOSET MAIL
It BATH TUB ADDRESS
—SHOWER CITY TEL NO.
CONTRACTOR
LAVATORY
SINE ADDRESS e j7J
DISHWASHERCITY TEL. NO.
CONT TOR STA �T
LAUNDRY TUB REGISTRATION NO. COUNTY 0 ,
CLOTHES WASHER DISTRICTNO. GFUAI PZQNE P= CESSED BY
/. WATER HEATER --L V,frL1.4
GAS SYSTEM INDUSTRIAL.
.WASTE APPROVAL
INSPECTION RECORD
.I I
0 $1.00 PER ITEM
/Q
OR FIXTURE $ Q U
APPROVALS (n/R DATE INSPECTOR'S SIGNATURE
PERMIT $ Z 00 UNDER 5 WORK
TOTAL FEE pp ROUGH PLUMBING .F9. LC- n• 7'� /U/I/G✓
Iy0 GAS PIPING �1
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS PPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
' WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULAi1NG T HOWATER HEATER
PLUMBING. _
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OA I PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AN STATE OF GAS TEST e
CALIFORNIA' OR THAT 1 AM THE'LEGAL OWNER OF THE ABOVE �• I
DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO.NOTQf1
SIGNATURE
OF PERMITTE
FINAL
®. VALIDATION Roe RT A. WOOD.
o Y.o. GSH SUP RV]SING MECHANICAL ENG'R
No Ery T/L G sw Ow iQ �
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