HomeMy Public PortalAbout5729 KAUFFMAN AVE_Plumbing__ ION
WOthat I have
a certificate
of consent to 76A666DPW9189 APPLICATION FOR PLUMBING PERMIT
' 76A667A
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished. �C
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRE S 7
F-1Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date Applicant WATER CLOSET
Inv NEAREST, /
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST: �i` �E
COMPENSATION INSURANCE ASSESSOR
^^��
(This section need not be completed if the work involved by the SHOWER MAP BOOK f�dG PAGOe0l' PARCEL6:57�;�Z
permit is for one hundred dollars($100)or less.) LAVATORY OWNER
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS 5
become subject to the Workers'Compensation Laws.
I ,!.a^^� DISWASS W CITY TEL.NO.
Date E ((� Appf,after/(maki/ng CLOTHES WASHER CONTRACTOR /�,}
NOTICE TO APPLICANT: If, after making this Certificate of �D�®��_C�A4f
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS a�� A/ D
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM p
LICENSED CONTRACTORS DECLARATION WATER H CITY �j/ s/1,2LT- TEL.NOg q6 q
I hereby affirm that I am licensed under provisions of Chapter 9 �+
(commencing with Section 7000 of Division 3 of the Business and STATE 0 9 LIC.
( 9 ) � LICENSE NO. ��/��� / CLASS
Professions Code,and my license is in full force and effect. GAS SYS M OUTLETS
OUTLETS OVER DISTRICT � PROCESSED BY
5 PER SYSTEM
—3c,
License Number ��'"�� Lia Class ``'� 0
�y 2 FINALI b` LLI
`9�'" ' Date DATE VALIDATION 1
Contractor h (�
❑ I am exempt under Sec. d BY AL -
BAP.C.for this reason t.,-•r•r a
Plan check fee
Date: — -
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
1 lTE�I'�
El 20
Plan check applicant �a ' [i_i (}c L 8�—' '°
LY
SINGLE FAM
HOME OWNER-BUILDER(DECLARATION Name NECr`•
L�a
-ikl.i
i
I hereby affirm that I am exempt from the Contractor's License Lawt,
for the following reason (Section 7031.5, Business and Professions Address (,,�H UE ,f_[ €
Code):
❑ City Tel. No.
I,as owner of the property,will do the work and the structure di
is not intended or offered for sale (Section 7044, Business 1900CI-II;,IC,1 �;�i9i i
and Professions Code). 0. 1—1 q q ��
1 1 t :-_t
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097,
Civ. C.)
Lender's Name
Lender's Address
I gertify 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 my to enter upon the above-mentioned
property for in ecti SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date