HomeMy Public PortalAbout9515 PENTLAND ST_Plumbing__ TION
WORKERS cI have" certificate
of copse - APPLICATION FOR PLUMBING PERMIT
hemby affirm thTION
at have a certificate of consent to self - 76A6 7A '
insure or a certificate of Workers Compensation Insurance, CE 817(REV 10/811
or a certified copy thereof (Sec 3810 Lab C ) COUNTY OF LOS ANGELES .. BUILDING AND SAFETY
Policy No Company
El- Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRIM OR TYPE) BULLRING
F1Certified copy is filed wrih the county building inspec- ADDRESS
tion department Ii NUMBER FI%TURE OR ITEM FEE -
IOCALITY
Date Apphccat WATER CLOSET l NEAREST pp'
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST GJ7" 17,Gl�
COMPENSATION INSURANCE OWNER ,
,(Thu section need not be completed if the work Involved by SHOWER
the permit is for one hundred dollop ($100)or Ins ) LAVATORY It
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 ! �_
Dpte�Plicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Cerhfimte of '�r- _• '
Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR
Compensation provisions of,the Labor Coda you must forth CITY TEL NO
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE 7
C
deemed revoked WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT No PROCESSED BY
I hereby off irm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER r 1
and Professions Code and my license is in full force and effect 5 PER SYSTEM FINAL 1 VALIDATION O
1 DATE V
License Number Uc Class pe
'
FINAL, O
Contractor Date BY _
- U U
❑ W
I am exempt under Sec d
N
' B &P C for this reason Z
Plan check fee '
Date
PLUMBING PERMIT ISSUING FEE E
Signature
TOTAL FEE O ,
'
SINGLE FAMILY Plan check applicant :a0 8(C 7 A
`
HOME OWNER BUILDER DECLARATION Name > -� 5
I hereby affirm that I am exempt from the Contractor s License f
Low for the following reason (Section 7031 5 Business and Address
._
Professions Code) City � � Tel No " r O
❑ 010 �'UQ505
'lies owner of the property, will do the work and the '010
structure is not intended or offered for sale (Section _ , 04.3 0,—8 4 '
7044 Business and Professions Code) i
CONSTRUCTION LENDING AGENCY i
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 ) r
Lenders Name `
Lenders Address'
I certify that I have read this application and state that the ,
above informationms correct I agree to comply with all Count
ordinances and State jaws regulating` Plumbing and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes
„� SEE REVERSE FOR EXPLANATORY LANGUAGE
!!lf�GLlO�- D�.,. f
ignatu re of Per Utee '