HomeMy Public PortalAbout5426 PARMERTON AVE_Plumbing__ I hi
RS COMPENSATION DECLARATION rseas».
that I have a certificate of consent to self CC0O (a-aa) •APPLICATION FOR PLUMBING PERMIT
ticate of Workers Compensation Insurance or
thereof(Sec 3800 Lab C) / �� BUILDING AND SAFETY `
' COUNTY OF LOS ANGELES
Company - -
Po�hffted cpy is hereby furnished FOR APPLICANT TO FILL IN )PRINT OR TYPE) BUILDING
Yo n
I ADDRESS Q
Certified copy is filed with the county budding inspection NUMBER FIXTURE OR ITEM FEE
D LOCALITY
department WATER CLOSET
Date Applicant NEAREST •
BATH TUB CROSS ST '
CERTIFICATE OF EXEMPTION FROM WORKERS '
COMPENSATION INSURANCE SHOWER OWNER n Y
MAIL !
(T1115 SeC[IOn need AOI be completed If the WO[k involved LAVATORY ADDRESS �Q "'s't�.—TOr IL
by the permit is for one hundred dollars ($100) or less)
SINK CITY �i�• /6 �•�� TEL NO L)
I certify that in the performance of the work for which this DISHWASHER • .�1 1 1 W
permit is Issued 1 shall not employ any person in anv manner CONTRACTOR [!I i Q r— 0
so as to become subject to the Workers' Com
/p/G/pselion Laws CLOTHES WASHER ADDRESS [.'� �',ti^ �. U
Date-'r6 i Applicant -,�:l7 2Z /11 WW
SWIMMING POOL RECEPTOR jCL
NOTICE TO APPLICANT If after making this Certificate of CITY Al V) s T U 4 TEL NO ij/r y
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE ry LIC .�� Z
Compensation provisions of the Labor Code you must forth WATER HEATER LICENSE NO /��2� CLASS
with comply with such provisions or this permit shall be DISTRICT NO R ESSED BY
deemed revoked GAS SYSTEM OUTLETS
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
1 hereby affirm that 1 am licensed under provisions of Chapter 5 PER SYSTEM r
9 (commencing with Section 7000) of Division 3 of the Busi FINAL /C6 q _Zz q VALIDAT N
ness and Professions Code and my license is in full force and DATE a
effect �' f
License Number `--'+�, /)/ f- � Cie Cla��slIsD)) 6 BV FINAL
Contractor ��034t I1C•-' Date �% Ti3<t C i )
1 em exempt from the licensing requirements as I am a Plan Check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEES C.�j(/ ( v ;?0098A
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) I
TOTAL FEE # a e a e 5
Lic or Reg No Date Plan cheek applicant 2 • 1 6 0 0
HOMEOWNER BUILDER DECLARATION Name ,a • • 1 6 0 0 c5 ,
Address
1 hereby affirm that I am exempt from the Contractor's 0'6 2 b—8 1
License Law for the following reason (Section 7031 5 Busi City Tel No ,
ness and Professions Code)
1, as owner of the property am exclusively contracting
with licensed contractors to construct the project '
(Section 7044, Business and Professions Code) -
CONSTRUCTION LENDING AGENCY
1 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 certify that I have read this application and state that the
above information is correct 1 agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing and hereby
authorize representatives of this County to enter upon the
above mentioned p�r/o�per/[y/y/y/////f/9,r inspection purp
�oses ,
X) 2/ AMY 2—ZI 1-01,
Si nature of Permittee Date