HomeMy WebLinkAbout1574A WORKERS' COMPENSATION DECLARATION P I TI L I I
I hereby affirm ihaf I have a cerfificate of consent to self 20-0026 DPW 6/S7
insure, or a certificate of Workers' Compensafion Insurance, 76A667A
or a certified copy ihereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORI<S -
Policy No.���� Compa�y ���d"-LPdI�-L`T
� Certified copy is hereby furnished. ��°'��� �T���
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ��
Certified copy is filed with the county building inspec- ADDRESS � (ti'�Yl�;�'J�,jf'�_.�'}���7/'�'.,
fion department. NUMBER FIXTURE OR ITEM @ FEE ������� ���,..�
��' , WATER CLOSET ��CALITY �
Dale Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.�' p � ���j/�1 SC � �o�it��
COMPENSATION INSURANCE OWNER��
(This section n�ed no4 be campl�4ed if fh�work involved by SHOWER � / ��' ,�� FA � ,
fhe ermit is For one hundred dollars 5140 or less. MAIL
P � � � LAVATORY '`� � '
ADDRESS, ' f � . r�
I cerfify fhai in the performance of the work tor which this
permit is issued, I shall not employ any person in any manner SINK CITY �}'�c- TEL. NO`f����>O��J
L�i
so as to become subjed to the Workers Compensation Laws. DfSHWASHER
CONTRACTOR ��f�..�� � �� � � ,�-� - �
f�L
Date Applicani CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of j������ )� "/�1/--1� /`�%�y�=
SWIMMING POOL RECEPTOR �-'-
mption, you should become subject to the Workers' )
CITY . TEL. N � � -�
�pensation provisions of the Labor Code, you must forth- � ���1���' `�`� 7�/G� c
LAWN SPRINKLER SYSTEM
with comply with such provisions or fhis permif shall be � STATE ��� j -r LIC.
deemed revoked, WATER HEATER LICENSE NO. r-�Ct.c�C� CLASS �-��
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR CESSED BY
I hereby affirm ihat I am licensed under provisions of Chapfer 9 GAS SYSTEM OUTLETS �jj
(commencing wiih Section 7000) of Division 3 of the Business OUTlETS OVER �j/ �� ��"'"�
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ��ll���l��
License Number���"����� Lic. Class '-�'��'� DATE
��i'tp.Ge�� l�'�A���r'/�., � �`�,�� BIY AL
Confraciqr / Date
❑ I am��rc(p�nde"r Sec.
B.&P.C. for this reason
Plan check fee
Dafe: PLUMBING PERMIT ISSUING FEE$
Signature � ��`
TOTAL FEE � ��.
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
'' �reby affirm thai I am exempi from the Coniractor's License Address
for the following reason (Secfion 7031.5, Business and
n�fessions Code): City Tel, No. �
❑ I, as owner of the property, will do ihe work and ihe
sfrucfure is nof iMended or offered for sale (Seciion ,
7044, Business and Professions Code).
CONSTRUC710N LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of 1he 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 correcL I agree io comply with all County
ordinances and State laws regulating Plumbing, and hereby
e representatives of Ihis County to enter upon the
� above- entioned ty for inspedion purposes.
, SEE REVERSE FOR EXPL,4PIATORY L/iNGl1AGE
� ., .��� ` ���.�v � � � ��'
Signature of Permitiee D te