HomeMy WebLinkAbout1577A WORKERS' COMPENSATION DECLARATION ' � F I I
I hereby affirm �hat I have a cerfificate of consent to self 20-D026 DPW 6/87
insure, or a ceriificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORI<S
paolicy NonJ��J°-�' Company ���"(�'`� �1.�'�� �` �i '� �C3'�� ��
Certified copy is hereby furnished.
fOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �.
� Cerfified copy is filed with the county building inspeo- ADDRESS �'� , �Ct/yry Td� G� ��
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date � � , Appli4ant WATER CLOSET NEAREST�/ �D L� ����--��
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CRO55 STe�/!'�177fJ a�� �/(�f?�F -'k7s�-a.PG�
COMPENSATION INSURANCE SHOWER oWNER ��,-77f�1.�..�� G���,���8�;�/f�
(This sec4ion n�ed no4 b�cample4ed i#4h�wrork iavolve�l by `�'v�"
the permtt Is for one hundred dollars (�100)or less.) LAVATORY MAIL c
ADDRES /�� � /,�L�J� �r" � ,/
I certify thal in the performance of the work for which ihis
permif is issued, I shall nof employ any person in any manner SINK CITY ��.��� �!���`�� TEL. NO ��� r3�� Q�
��
so qs to become subject io the Workers'Compensafion Laws, DISHWASHER �
CONTRACTOR���uS� p .� �} �
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS ���� ��� ,���ya ���
mpfion, you should become subject to fhe Workers' SWIMM�NG POOI RECEPTOR -
CIT���' TEL. NO� � `
mpensafion provisions of the Labor Code, you musf forfh- � d �e."�[� 7/f°7�J//;a3'O
� LAWN SPRINKLER SYSTEM � �
with comply with such provisions or ihis permit shall be STATE / / LIC.
deemed revoked. WATER HEATFR LICENSE NO. ��t�tcj��� CLASS �p��
LICENSED CONTRACTORS DECLARATION DISTRICT No.d OCESSED BY
I hereby affirm that I am Ilcensed under provisions of Chapter 9 GAS SYSTEM OUTLETS . � �
�'",/t,a,,. i�r_ yst.�
(commencing with Section 7000) of Division 3 of the Business OUTlETSOVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL � \//,�ll��`p��Rj
license Numberti=/��'���� Lic. Class �`�'� DATE
�/��� /„�� ,el/�� �� FINAL
Contractor �d'�'T�`�`�'f Date Z�`� BY
❑ I am ex���e�e�i"�'�c- ��`�a�.��j�
B.&P.C. for ihis reason Plan check fee
Date: pLUMBING PERMIT ISSUING FEE$ ����
Signature �
TOTAL FEE r� �
Plan check applicant "
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name . ` � ��
�reby affirm that I am exempt from the Contractor's License Address
- for the following reason (Section 7031.5, Business and
rrofessions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
strucfure is not intended or offered for sale (Section
7044, 8usiness and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm thai there is a construction lending agency for
the performance of ihe 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 corred. I agree to comply with all County
ardinances and State laws regulaiing Plumbing, and hereby
a ize representafives of this County fo enfer upon fhe
above- enfioned pGe}�ty for inspection purposes.
SEE REVERS� FOR EXPLAiVATORY L�4NGUAGE
���„� �'���a�.. �/�����,
Sign ture of Permitte Date