HomeMy WebLinkAbout1576A WORKERS'COMPENSATION DECLARATION I TI F I IT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a cerlificate of Workers' Compensafion Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) GOUN7Y OF LOS ANGELES DEPT. OF PUBLIC WORKS
P❑olicy No.�Sa���-r�°�Company�"Tf�%� ��y ���'7''i� �,t�`�' ,;�„��
Certified copy is hereby furnished.
� FOR APPLICANT TO FILL IN(PRWT OR TYPE) BUILDING 4
Certified copy is filed with the county building inspec- ADDRESS � � rdj .T�gd_ �
fion d parlmenf. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY `������� ���
Date � '� � Appli4aM WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST�i � �' ��1-� � ���
COMPENSATION INSURANCE oWNER`,R_ %� i�¢�-l�� ���.C.I�A'�='=.tJl� -��t�.
(This section need no4 b�comple4ed if 4he work involved by SHOWER
fhe permit is for one hundred dollars ($140)or less.) LAVATORY MAIL r
ADDRESS�✓�j �i�;,�J/i� �
I ceriify ihat in the performance of the work for which fhis
permii is issued, I shall not employ any person in any manner SINK CITY _ TEL. N p�
` YY�E�.-'`s� JC�f 0 fSC}-/�:Y�/
so as to become subjecf fo}he Workers Compensation Laws. DISHWASHER / ,�-
CONTRACTOR� _��; �`��� ����� � —
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS ��� .l ��y��� ��,
mpfion, you should become subject fo fhe Workers' SWIMMWG POOL RECEPTOR
CITY����j> � TEI. N
npensation provisions of the Labor Code, you must forth- t° LAWN SPRINKLER SYSTEM ��,z ��� �'� �ry �� l�=
with comply with such provisions or this permit shall be � "STATE --9 LIC.
deemed revoked. WATER HEATER LICENSE NO.,�„��/�,�(. CLASS C�-��
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �� ���
(commencing wifh Section 7000) of Division 3 of the B�siness OUTlETS OVER � - f � "
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL \/�Ll��gl��
DATE
License Numbec_�ZC ���9 Lic. Class �'-��
c
� i,��1 � �� FINAL
Contractor��'/1����/1�;1�����fi Dafe � /°7 BY
� '�h1�' ��/o,t76�s c.-
1 am exempf un�der 5ec,
B.$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 ihat I am exempt from the Contractor's License Address
for fhe following reason (Section 7031.5, Business and `
rrofessions Code): City Tel. Na ; i '
❑ I, as owner of the property, will do the work and the
sfructure is not infended or offered fo� sale (Section �
7044, Business and Professions Code).
CONSTRUCTION LENDING AGCNCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which Ihis permit is issued
(Sec. 3097, Civ. C.),
Lender's Name
Lender's Address
I cerfify fhai I have read this application and state that ihe
above informafion is correcf. I agree to comply with all CouMy
ordinances and 5tate laws regulating Plumbing, ond hereby
authorize repre`sentaiives of this County to enter upon the
a ove entionedF,pr•eper.tj� for inspection purposes.
) SEE REVERSE FOR EXPLAPIATORY LANGUAGE
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:���. �2�. . -` � r � ��
Sig ture of Permitfee Date