HomeMy Public PortalAbout9660 LA ROSA DR_Plumbing__ /L
WORKERS't I have
. certificate
DECcafe of cons " APPLICATION .FOR. PLUMBING PERMIT
— f hereby affirm that I have a certificate of consEnl 9o'seif, 176t,667-A 's
insure, or a certificate of Workers' Compensation Insurance, ,CE BI7(REV. 10/8I) —�
or a certified copy thereof (Secs. 3R, Lab. ) ,J
��,, rL 7O I COUNTY OF LOS ANGELES / C- BUILDING AND SAFETY
Policy No.�%Q_—_✓—�pul� la JAL Sk &,
Certified copy is hereby furnished ! q
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDLDING
RESS re C:�' �/v
Certified copy is filed with the unty b 'Iding inspec- a
1 NUMBER FIXTURE OR ITEM r FEE LOCALITY
tion deportment. Q
n.� WATER CLOSET G,x TIN r[/r
Date 6770 Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' I / BATH TUB CROSS ST, .if i, Ly
COMPENSATION INSURANCE - OWNER
(This section need not be completed if the work involved by f SHOWER Lr i
the permit is for one hundred dollars 5100 or less. MAIL /•�. LA �.
P ( ) ) LAVATORY ADDRESS [), W'
('certify that in the performance of ih work for which this I .
permit is issued, I shall not employ an ;person in any manner SINK CITY TEL NO. Z
so as to become subject to the Wor 's'Comp sation Laws. DISHWASHER -
CONTRACTOR J l
Date e Applicont CLOTHES WASHER
�?
NOTICE TO APPLICANT; If, aft r making this ertifi of ADDRESS .
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY JJ q r^. TEL. NO.2
LAWN SPRINKLER SYSTEM %A[Gt S/SN/� Cg L"
with comply with such provisions or this permit shall be STATE �rI LIC.
deemed revoked. WATER HEATER LICENSE NO. ��� �� CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT.NO. pR E55Eo aY
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 U� d
and Professions Code,andel my license is in full force and effect. 5PER SYSTEM FINAL �J jyr�c VALIDATION {O.1
32 0 8-c DATE (/� �O C7(J
License Numb r Li<. Class a.
'�[/ FINAL `F O
Contractor M �/ ' '� Date Se "• - U BY. - V
❑ I am exempt under Sec. / 0.
(� N
B.BP.C. for this reason
Plan check fee '
Signature Date:
PLUMBING PERMIT ISSUING FEE$ (, �a
TOTAL FEE (j J-0
Plan check applicant
SINGLE FAMILY
HOMEOWNER-BUILDER DECLARATION Name
I I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address J.l.
Professions Code): Gly 1 Tel. No. Z ��$OSO ��$ 4•$Q
❑ I, as owner of the property, will do the work and the # e e e e e 5
structure is not intended or offered for sale (Section - ,
7044, Business and Professions Code). l e e ,7 Q 5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for • el--T(1506
the performance of the workfor which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I c/ese
have read this application andstatethat the ,
abion is correct. I agree to comply with all County
ord State ws regulating Plumbing, and hereby
ounta ves of this County to enter upon the
abed operty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Ilea— 851
Signature of Permittee Date - ,