HomeMy Public PortalAbout6247 GOLDEN WEST AVE_Plumbing__ DPW 9
'"'°,8co" Aloate°�ent to 78WA °° APPLICATION FOR PLUMBING PERMIT
I Ji$reby ht}trm that-/have a wrUfloate"oT cor}sent to ul�inpute,
or'&oertffloato df Workers Compensation Piurance, or a cortlfled
(C�omI COUNTY OF LOS A GEI DEPT.OF PU13UC WORKS DEPT. CRUPLIC:WORKS DIV.
I❑ Cut}Md copy Isrhereby hYnieftetl. FOR APPLICLAMT TO FILL IN(PRPIT OR TYPO BtnL00'1a r
Cw led copy Is fl led with the corrty bud"I nopeotion NtA®Si FDCftIRE OR lTEtl • FEAHS
/�") 7l /�+ LCCALrry
Date AT1oant l r r r 1 � WATER CLOSET A NEAREST
Caoes ST.
CEITTFliCATF,OF E g3APTION FRDM WOR_KEFt& BATH IUB �/ Q
COMPENSAT)ON INSURANCE
{Thio eeotlon neednot be"plated if the work fnvotwd by the SHOWER MAP B004( PAGE PAFIC7
LI
permit Is for or»hta►dred do0ars($100)or baa.} OWNER C
I oerttfy that In the performance of tho,work for,whloh this permit LAVATORY
MAL
n
Is Issued, I shall not employ any person In any manner so as to 8NK ADDflEW
become wNect to the Workers'Compensation Laws.
4t9WA9HER CITY T1921,40.
Deb APpill—d CLOTHES WABHER
NOTICE TO APPLICANT: It, after making this Certificate of
Ezemption,you should beoome subject tc the Worksrd'Compormatkm 81MMU ip POOL RECEPTOR �
proylsions of the Labor Code, you mW forthwith oompty with such ADDRESS
proyle"or this permh shall be deerrisd revoked. LAWN 8PRHN10_EA SYSTEW CITY TEL
rUCEN8ED CDNITRAhapter CYOR$DECLARATION
I hereby&Mrm that I im Ilosnsed under provld)ons of C9
� WATER HEATER
�L� S
(oommenoing with SeaHon 7000) of Division 3 of the Busln and GAS SYSTEM OUTLETS / �lxl NO !�p Cgg G`� 3�
Profees7ons Code,and my license Is In full force and eMacL
Lkrerne Number ua c✓ae.� ovER O . �:.,;- �-�I BY
&MA
Cantr+ctar��,Gl�( �n__r__�f D.t@. " o-DATE . TION r� rt W
El em axempt ardor Sea FWAL 330717 !1.10 z
,(
B-eP-C.fpr this reason 1 IfE�1S
Plan heck f06
819r� PLUMBING PERMrr MUINt3 FEES
TOTAL FEE .2 Q i 0ECi 7TH.IC(
❑ Plan cFterJc appfaartt 1.�rAZ •W
8fN(GLE FAMILY
HOME OWNER-BUILDER DECLARATK)N Nemo /�y 771p�
I hereby&Mrm that I am exempt from the Contraotor'e Lbense Law r� ��fW1 11/1.1I7L
for the following reason (section 7031.5,Bushes*and Professions Address
,Code): �'Ctty Tel.No. GDTO t �
❑ 1,u owner of tfre property,lalll do the work and the etruot no 1 1711Q�17
to not Intended or offered for sale(Seatlon 7044, Business
ind Profeealons Code). ,
CONSTRUCTION LENDING AGENCY
I herby aN1rm that there Is a construction lending agency for'the
pedormsnde pi the wont for whloh thls permit to lssued(Seo. 3097, ti
Civ.C.)
Lenders Name
LerKWs Addrees
I certify that I have read this applloation and state that the above
info I agree to 0o ly with all County ordinances
an hate Also regulating Plu ng, and hereby authorize
rep of this County t or pon the above-mentioned
f pub- h SEE FEVERSE FOR DP~TORY LAHOUAOE
01
grtature of Perin