HomeMy WebLinkAbout1553A WORKERS'COMPENSATION DECLARATION qPPLICATION FOR PLllnll�INC� PERMIT
I hereb affirm ihat I have a certificate of consent to self in- 20-0026 DPW qie7
Y� 76A667A
sure,or a certifimte of Workers'Compensation Insurance,or a CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.) ��
Policy No�����d Company �l�`��—/.n�JL� COUNTY OF LO$ ANGELES DEPT. OF PUBUC WORKS `>> �'�`
� Certified copy is hereby furnished. � �",, �
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING L/
� Certified copy is filed with ihe county building inspection ADDRESS �-, -�j "�; �L�/�7/7'J( J�G�'Z'���
depariment. NUMBER FIXTURE OR ITEM �d FEE LOCALITY �"�y
� � �� WATER CLOSET(TOILET) � ``����}�'� ��
Date Applicant NEARES � .
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS S�,f�JJ'� � � _ ��/��Jv ����
COMPENSATION INSURANCE OWNER � `�
(This section need not be completed if the work involved by SHOWER �- � �� �_�1���/�//� "� �,
MAIL
}he permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS � �/ �"j�" �
I certify that in the performance of the work for which this per- SINK �
mit is issued, I shall not employ any person in any manner so CITY�j�r ��� �� TEL. N ..-���/I�� ��/
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as to become subject to the Workers' Compensation Laws. DISHWASHER —
CONTRACTO _ - � ��������� d ji,��, -
�f4�
Date ApplimnT CLOTHES WASHER `
N "CE TO APPLICANT: If, after making this Certificate of Ex- Ao�REss ���,7��O f'�'?�7��,�yc� ����C��,
� ,on,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR �__---_�
sation provisions of The Labor Code,you must forihwiTh comp- LAWN SPRINKLER SYSTEM CITY �f��r��� ��; TEL. NO. ' � �,�y
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NQ,��Lc- L� C� CLASS �,- ��
LICENSED CONTRACTORS DECLARATION DISTRICT No. a OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of The Business OUTLETS OVER ���� "��
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. �j DATE �d G�•'; �
License Number������Lic Class �"��- /
{�-----��. �,�,,i �/ FINAL
Coniractor/ �i���•`���-"'�"`����te �l� �O BY � ti-'
��Tbm�emp'Yurn�Sec� ���J��
B.&P.C. for ihis �ea5o� � Plan check fee
Date: ' !
PLUMBING PERMIT ISSUING FEE$ � -,�
Signature �
TOTAI FEE �
SINGLE FAMILY p�an check a licant '
HOME OWNER-BUILDER DECLARATION PP
I hereby affirm ihaT I am exempt from ihe Conirador's License Name ��`" ` � " �" '
I for the following reason (Section 7031.5, Business and
' ssions Code): � Address 1 � "� � �'� ;":i_;�
� I, as owner of the property, will do the work and the City Tel. No.
siructure is not intended or offered for sale(Seclion 7044,
Business and Professions Code). � � (i �', �j
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consiruction 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 ceriify ihat I have read ihis application and state fhat the �
above information is correct. I agree to comply with all County
/-��`nanc�s and State laws regulating Plumbing, and hereby
� authorize�preseM ue�-.�of fhis County to enter upon The
above- entioTsed-. roperty f�r inspection purposes.
___-, ,���� ,����: � ^ �' i� SEE REVERSE FOR EXPLANATORY LANGUlACsE
�.�._.�__. � /'.7 �
� SignaF re of Permittee Date