HomeMy WebLinkAbout1573A WORKERS' COMPENSATION DECLARATION I I I IT
I hereby affirm }haf I have a cerfificate of consent to self 20-0026 DPW 6/87
insure, or a ceriificate of Workers' Compensation Insurance, 76A667A
or a certified copy ihereof (Sec. 3800, �ab. C.) COUNTY OF LOS AfVGELES DEPT. OF PUBLIC WORKS
P�olicy No.�Company .����'���d A�� �
Certified copy is hereby furnished. � y 4����
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �t �., l ✓ /�
� Certified copy is filed with the county building inspeo- ADDRESS � ,��, c� )'/,�/'��l� �..--1�s�
tion deparimenL NUMBER FIXTURE OR ITEM @ FEE LOCALITY
e�� WATER CLOSET �/� �"�l7 ���v�
Dafe � f vx _Appli4anl NEAREST�`� '7 ,a
CERTIFICATE OF EXEMPTION FROM WORKERS' BAT.H TUB CROSS ST� f�J/I7�1�G� �1��+�-'���-/�i'�«
COMPENSATION INSURANCE SHOWER OWNER�� �� ,��. �'������.�7 £�-�.
(This section need not b�completed if the work involved by MAI�
the permif is for one hundred dollar� (;100)or less.) IAVATORY ADDRESS ��� �l���13 `
I cerfify fhat in Ihe performance of the work for which this - y`s
permit is issued, I shall not employ any person in any manner SINK CITY��� � ,,���� TEL. NO. 7�,t/�s,;�b ��
so as to become subject to the Workers'Compensation Laws. DISHWASNER
CONTRACTOR���f � �
Date Applicant CIOTHES WASHER s ; f .�"�..�J
ADDRESS z
NOTICE TO APPUCANT: If, after making this Certificate of �/�� s
m tion, ou should become sub'ecf fo the Workers' SWIMMING POOL RECEPTOR ,.--
P Y � CITX 7 - TEL. NO ja�
npensation provisions of ihe Labor Code, you must forth- �' LAWN SPRINKLER SYSTEM �. �'� � � ��� � � �'� ['
with comply with such provisions or ihis permit shall be STATE LIC. i
deemed revoked. WATER HEATER LICENSE NO. �-�-z,�L�,/ �j CLASS �'�+
LICENSED CONTRACTORS DECLARATION DISTRICi NO. PRO SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS � � �
(commencing with $ecfion 7000) of Division 3 of the Business OUTLETS OVER �`"�'��'-'
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ������'�'I�Rj
License Number ������'(=� Lic. Class ��� � DATE
�y�, � BY AL
Contractory r�//,��L�� �ate �
❑ I am eSLce�n_���'..��7� �l„�!'J��f+
B.�P.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ � ��
Signature
TOTAL FEE �, ��>
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ''
' ' >reby affirm that I am exempf from the Contractor's License Address f ! �
for the following reason (Section 7031.5, Business and
r�ofessions Code): City Tel, No.
❑ I, as owner of the property, will do the work and the
shucture is not intended or offered fo� sale (Section '' `.' .
7044, 8usiness and Professions Code).
CONSTRUCTIOhI LENDING AGENCY
I hereby affirm that there is a construdion lending agency for
the performance of the work for which fhis permif is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I cerfify ihal I have read this applimtion and state that ihe
above information is correct. I agree io comply with all County
ordinances and State laws regulating Plumbing, and hereby
autho 'ze repre`sentatives of this County to enter upon fhe
above- enlioned rope ty for inspection purposes. SEE REVERSE FOR EXPLE�P9AT�RY LANGU�eCaE
t���` �'.���-�/-� �' �`� ��'
�Signat re of Permittee, Daie