HomeMy WebLinkAbout1575A WORKERS'COMPENSATION DECLARATION � `r� � �
I hereby affirm that I have a cerfificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBIeIC WQRI<S -
p�oli�y No7���--�" Company �(�'1'�. �tilL7 ��i�� ��C�"���
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL W(PRINT OR TYPE) BUILDING�
Certified copy is filed with the county building inspeo- ADDRESS p ��. -,�`� �/J7t{ �f�,�
tion deparfinent. NUMBER FIXTURE OR ITEM @ FEE �OCALITY � /
L f ( WATER CLOSET �/�,����� ���/
Date � Appli4anl NEARESk—ry�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CR05S Si�//�"�� c��� `�'��'�-��
COMPENSATION INSURANCE OWNER � 9
(Thlt secfion ere�d nof b�eompl�ted if 4ho werk involv�d by SHOWER � � �� � �if�-.� �3c i��J� �
4he p�rmit is far one hundred dollar� ($100)or I�cs.) LAVATORY MAIL
ADDRESS��L� LlJ� �CJ �-�`��� . �
I certlfy that in the performance of the work for whicl7 this
permif fs Issued, I shall nof employ any person in cany manner SINK CITY TEL. NO
�.S / f� �� 7 � 1
so as to becoma subjeci to the Workers'Compensation Laws. DISHWASHER �Y
CONTRACTOR .� ^�
�� � ���� 0 1
Date Applicant CLOTHES�NASHER ADDRESS r7 � �►,,;, c `Jt�`
NOTICE TO APPLICANT: If, after making this Certificate of � � ,✓ �� ��-�� ��
SWIMMING POOL RECEP70R
mpHon, you should become subject to the Workers' r'`i�
CITY - � TEL. NO � s
npensation provisions of the Labor Code, you must forth- �' LAWN SPRINKLER SYSTEM �� ��� �f� J`�����
with comply wiih such provisions or this permif shall be STATE .� ` LIC. �
deemed revoked, WATER HEA7EI2 LICENSE NO. .�,��c��� CLASS �- Y-��
LICENSED CONTI2ACTORS DECLARA710N DISTRICT No, PRO SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAs SYSTEM oU7LETs
(commencing with 5ecfion 7000) of Division 3 of the Business oUTIETS OVER
� ���� ��
and Prof�ssions Code,and my license is in full force and effecf. 5 PER SYSTEM FINAL ��(,I��jB��
LicenseNumber�-=-- ����-�� �"•�-�i DATE
_ � fLlic. Class -
� �� � FINAL
Contracfor����6����,�Date BY
❑ I am��p�d r Ser:�rJ�vF i�-� ������J�[
B.&P.C. for this reason
Plan checl<fee
Date: PLUMBING PERMIT ISSUING FEE$ � �
Signafure
TOTAL FEE � ��
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name :
' �reby affirm that I am exempt from fhe Contracfor's License Address
for the following reason (Section 7031.5, 8usiness and �_
Nrofessions Code): City Tel. No.
❑ ( , .
I, as owner of fhe property, will do the work and the
structure is not intended or offered fo� sale (Section
7044, Business and Professions Code). �
CONSTRUCTION LENDING AGENCY � '.
I hereby affirm that ihere 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 fhat I have read ihis application and state ihat ihe
above informafion is correct. I agree to comply with all Counly
ordinances and State laws regulaling Plumbing, and hereby
au ' e repre°sentatives of fhis County to eMer upon ihe
above-m tioned pr- erp�.{or inspection purposes.
� SEE REVEF25� FOR EXPLANATOltY La4NC,UA(eE
�' , ���<.�� �,� �/�'
Signat're of Permittee Date