HomeMy Public PortalAbout8756 GARIBALDI AVE_Plumbing__ ,�� ;;o�MP Nva aScAeTI°"at�corTION self In- DPW 4/97 - APPLICATION, FOR PLUMBING PE1�J�1AIT
sure,'or a certificate of Workers'Compensatlon Insurance,or a CL 817(REV:8/86)
certlfled copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P�Ilcy No. Company
Certffled copy Is hereby furnr&hed:
FOR APpiICANT TO FILL IN (PRINT OR TYPE) BUILDING •
Certified copy Is filed with the county buLlding i6spectlon NUMBER FIXTURE OR TiEM FEE ADDRESS /
department. LOCALITY
wArER QOSET(TciLET) n
date
Applicant v NEAR EST BATH TUB �_ .
CROSS ST.
CERTIFICATE OF EXEMPTION FROM-WORKERS' O ,
COMPENSATION INSURANCE OWNER
SHOWER
(T}rls sedlon nkd npt be completed If the work Involy d by MAIL
the permtt Is for one hundred dollars(;100)or Iuss.J / LAVATORY Q ADDS$
I certify that J th'erformdnce-of the work for which th15 per- i
pe SINK., '72
�'
mlT is issued, I&hall no ploy any-person in any rpahper
of�t'o^�becom/e su/b��JpY�} a Workers'Compenurl n DISFrWPSHER 4�>�ROR �!�—/ v L(//✓ �G�
(iaRtli �( `� Applicant QOTHES WASHER
�f ADORE
NOTICE TO APPLICANT: If,'after a this CeLWI
of Ex-
emptlon, you should become subl'ect to the Workmpen- SWIMMING POOL RECEPTOR CJfI TEL
satlon provlslons of the Labe Code,you m"uqt foo LAWN SPRIIJKLER SYSTEM ly with such provisions or this permlt shall be'devok- STATE NO f/Ad
ed; CATER HEATI�t !r?—►
LICENSED CONTRACTORS DEC} ATJON. ^O DISTRICT D BY
h b affirm that I am Ilcen&ed under rovlslo GPS SYSTEM OQ �}
yre y p n;� f Chppter (�7
9(commencing with$action 7000)of Division 3 of the Business 5 PH2 SYStEM
fend Professions Code, and my license is•Irr full force and ef- / FINAL VALIDATIO a
U DAV(2
Lrcente Number J_lc.'clasi
FI V 1M G✓!�'fv G Dare t ,D d x ~
• Contt&clot O
i--I
I am exeD pt under Sec. W
B.$P.C. for thisreason Plarr che ck fee Boo. wg
Date: PLUMBINC�PERMIT ISSUING FEES Q
Slgndtvrp TOTAL FEE2 8 9 a,O A
MI '
WNERBLJILD:R
INGE FALY '#foo o •t• 5 LA RATION Plan che¢ applicant
I hereby affirm that I arrlexem omtheContra rs License Name
X005250
Law for thQ following reason action uslness and 5 25 0
Professlons Code): Address �,0 0
is
I, as owner of the property, will do the work and the City Tel. No, 8 8
structure Isnot intended or of#ered for tafb(Sectlon7041,
Rusrn'ess dnd-Professions Code). '
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a constructlon lending ogenty for
thq performpnce•of the work for which this permit G Issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
1 certify that'] have read this application and state that the
above Information is correct.I agree to comply wJth all Covnt-y ,
ordinances and $tate laws regulatrng Plumbing, and hereby
authorize representatly f ounty to enter upon the
abov6 rhentlr ctlpn pu es.
SEE REVERSE FOR EXPLANATORY LANGUAGE r
t �Ipna PermlM Date /r
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