HomeMy Public PortalAbout5818 KAUFFMAN AVE_Plumbing__ +. • WORKERS'COMPENSATION DECLARATION APPLICATION FOR, PLUMBING PERMIT
I her,*by offirM that I have a certificate of consent to self 76A667A
-, sure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof eec 3800 a C.) COUNTY OF LOS ANGELES• BUILDING AND SAFETY
Policy No. C.mpany 11::�'✓D
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGs0 n ,'-7
❑ Certified copy is filed with the county building inspec- ADDRESS f / I
do depar ent.
NUMBER FIXTURE OR ITEM @ FEE LOCALITY C�(� ��� �i
a 16 &Vmv i WATER•CLOSET / Ar
Date Appli4ant ` CROSS 8T
CERTIFICATE OF EXEMPTION FROM WORKE S' BATH TUB
COMPENSATION INSURANCEI SHOWER OWNER ��M
(This section need not be completed if the work involved,by MAIL
Iee
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS: �T
O o'0✓%
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY' TEL. NO
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR• k1 LD Q
Date Applicant CLOTHES WASHER .�
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
.Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR ' a
Compensation provisions of the Labor Code, you must forth- CITY 0��V�A TEL; NO 3s/ —O
LAWN SPRINKLER SYSTEM.
with comply with such provisions or this permit shall be STATELIC
deemed revoked. WATER HEATER LICENSE NO 148119-)? CLASS ►J
LICENSED CONTRACTORS DECLARATION DISTRICT NO._-�/ CESSED BY
DU(I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ,
and Professions Code,and-my license is in full force and effect 5 PER SYSTEM
/� DAT-
License Number 2 Lic. Class I
FI r O
Date
Contractor
V
JV
I am exempt under Sec H
B.&P C. for this reason Plan check fee Z
Date: PLUMBING PERMIT ISSUING FEE$ O S
Signature
TOTAL FEE SV
Plan check applicant
SINGLE FAMILY ;2 3�9 a-2 A' •
HOME OWNER-BUILDER DECLARATION Name s` �}-0 0 0 0 o 5•
I hereby affirm that I am exempt from the Contractor's Licenser
Law for the following reason (Section 7031 5, Business and Address -;> o'2 5 _
Professions Code)- City M Al kD✓ Tel. No 0'0 0 2 5 v
❑ I, as owner of the property, will do the work and the
02.p5=86
' structure is -not intended or offered for sale (Section
7044, Business and Professions Code)
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 "ONE,
Lender's Address
Icertify 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
RbLe-Le ioned pro ert for inspection purposes. - -
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
. .. •,r`. 5- , tdt•:n:�iti. :)j,:- ,., ;,.,-.� ., ;.• ,� " a5,4T....l
'APPLICATION' FOR PERMIT
DEPARTMENT 'OF BUILDING,.AND.-SAFETY- NI
NTI' OF LOS
COU ;X14 ;ES
P U �IN
WM:'J. FOX CHIEP- ENOIN[ER
: a
NATURE OF I1d1STALLATION'' DISTRICT NO. .* GUP: ONE PERMtT No:.
ROUGH• s ',• Ij
PLUMBING ., FIXTURES COMPI[TE '
READY FOR, DA E 1 4
HEATER: CESSPOOL' BEPTICTANK (•j;rFIRBT;INSPECTION• -DATE
'-_1 '-„ ♦ /`' :,
ISCMLARROUS
APPLICANT,FILL IiEAVII,Y OUTLINED.'PORTION QNLY
on i.:: _ L
NAMEc'.'•'2% ADDRESS'
ol
ADDRESS, e" 'LOCALITY =c
O N EAR EST V�'V
;i CITY; TEL' No. i' CROSS"ST.
COUNTY
CERT. EXPIR
'NO.' ES,
� TIC TANK, OR CESSPOOL. ^.AD
LOCATION OF SEPDRESS
".G.' NORTH 4 C
ITY'
' •":r k' TEL
AMS'THE,`LEGAL 'POSSESSOR OR THE ABOVE
ANGELES COUNTY CERTIFI 7 F IrICA `
yr ;:,`�,� .h .. -'•;�,'; ,, _ - `�p
YMotR
.
`! 1 AM-THe LEGAL OWNER OF THE PROPERTY DESCRIBEDr
•ABOVE.
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CORRECTIONSL
rf SOUTH c
DESCRIPTION'OF WORK: '. :
-'BATH r1'u4, F.u,n—SHOWER
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_ ,'io. �s.'ii,.7-ia ialt;� •'��;, d::.:• ;�:;:;,�':,;,<;„`• '�APPL'ICATION`FU&_i �
DEPARTMENT OF.BUILDING AND SAFETY;';
J
COUNTY OF LIDS ANGELES ';:' '
WM. J OX 'CHIEF EN61N[ER' J`e^3 � •
DISTRIC
NATURE OF INSTALLATION"
ROUGH T_ O: cou r
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