HomeMy Public PortalAbout9144 EMPEROR AVE_Plumbing__ WORKERS' I hove SPTtifi dt ,of C lO APPLICATION FOR PLUMBING PERMIT
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Thereby, affirm thaYl hove a certific�t�.af cofis€-,?to,self i�- �6A667A
sure,,,or a certificate of Workers'ComF1'enx�;,on f)sjurance,or a CE 817(REV. 8/86)
certified co y thereof-'(Sec. 3800, Lab.
PblacjN� ��i Compa /f — COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
Certified copy is filed with the county building inspection ADDRESS
parllent. NUMBER FIXTURE OR ITEM �° LOCALITY
Date aT �� Applicanti�'� � �. WATER CLOSET(TOILET) 2 _ NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' � BATH TUB � Cw' _, CROSS SL
COMPENSATION INSURANCE SHOWER -, _ OWNER _
(This section-need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY el ADDRE o'1
I certify that in the performance of the work for which this per- r
mit is issued, 1 shall not employ any person in any,manner so SINK ,2y 3Z �i CITY ^D�
as to become.subject to the Workers' Compensation Laws. DISHWASHER -V
. ' S // CONTRALTO
Date Applicant CLOTHES WASHER 4O ADDRE D
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- C1
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM t J
ly with such provisions or this permit shall be deemed revok- STATE LIC.
/ WATER HEATER CLASS
ed. LICENSE S�
LICENSED CONTRACTORS DECLARATION GAS SYSTEM OUTLETS DISTRICT NO. --P—ROZESSED BY
I hereby affirm that I am licensed under provisions of Chapter U �g
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER � C�
5 PER SYSTEM
and Professions Code, a�nJdQmy/�license is in full f .ccee and/ef- FINAL VALIDATION
fect. /4 d �! CL
— DATE �� O
License Nu ber Lic. Class ^ U
+ Q FINAL — 99
0
Contract o Date *^- / UO BYMAI
O
(ft t^'
F-] U
I am exempt under Sec. LU
B.&P.C. for this reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE
SINGLE FAMILY
heck applicant
HOME OWNER-BUILDER DECLARATION Plan c �
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and �•f °$ .,
-r-r-
Professions Code): Address, 3307 163.5171
❑ 1, as owner of the property, will do the work and the City Tel. No. 1 ITEMS
structure is not intended or offered for sale(Section 7044; TOTAL :16 3 a 50
Business and Professions Code). ► .
'CONSTRUCTION LENDING AGENCY CHECK 1,�y j° 0
I hereby affirm that there is a construction lending agency for CHANGE 00
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
0000-00131 1/
Lender's Name
80391 PM 1".
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
ov men+td property for inspection purposes.
Z51 A SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date