HomeMy WebLinkAbout1578A WORKERS'COMPENSATION DECLARATION I TI L I � I
I hereby affirm that I have a cerlificate of consent ta self 20-0026 DPW 6/87
ins�re, or a cerfificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPI'. OF PUBLIC WORKS -
P❑olfcy Noj���Company ���� �u'�'�`�
Certified copy is hereby fumished. �`�`��� � �`�
^ fOR APPLICANT TO FILL W(PRINT OR TYPE) BUILDING
u Cerfified copy is filed with the county building inspeo- ADDRESS �j�, �, ��7 '� ���.
tion deparimeni. NUMBER FIXTURE OR ITEM a FEE
�1���9' WATERCLOSET LOCALITY ������� ����
Dafe Appl ica nt NEAREST ��,y�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST„(��l,�I�a�,1 �j� .��a<..1��1y �/ch'7,t-1L�
COMPENSAT�ON INSURANCE SHOWER OWNE ��r���� �����'��n�9� .���,
(This seetion need nof be completed if 4he uvoek involved by MAIL � ^ �/
Phe permi4 is for one hundeed dollars ($140) ar less,) LAVATORY ADDRE55�/.,j/ d7l��J/� �� c-,���� , N
I certify that in the performance of the work for which this
permit is issued, I shall nof employ any person in any manner SINK CITY � �v�1 TEL. NO
�C�.�a.� /�� �'GS� �!`� �',�Z}�-dOd
so as to become subject to the Workers Compensation Laws. DISHWASHER
CONTRACTOR����j� ������ fr��./� V-9„
�J�'sN
Date ApplicaM CLOTHES WASHER ADDRE55 ,;Z.
NOTICE TO APPLICANT: If, after making �his Cerfifimte of 1 �// f'7�d���/�U,!—fJ� /�-t,��=--�
mption, you should become subjed to the Workers' SWIMMING POOL RECEPTOR
npensation provisions of the Labor Code, you must forth- CIT�������s��„ TEL NO.
LAWN SPRINKLER SYSTEM �� 7��'��'
with comply with such provisions or this permit shall be r STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. "7 t f - CIASS �—�
LICENSED CONTRACTORS DECLARATION DISTRICT No. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapier 9 GAS SYSTEM OUTLETS ��
(comrnencing with Secfion 7000) of Division 3 of }he Business OUTLETS OVER ""�'g`���'`��
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL �/ALID14TICaVV
DATE
license NumbeF=-������ Lic. Class �'Z�
FINAL
Contractor�t'Q����`�����-Date �`�� �'� BY
❑ �-�,�.���;�;�:., �.�,,�,-��
I am exempt un er Sec.
B.BP.C. for fhis reason
Plan check fee �;
Date: pLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE � ��;
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
' �reby affirm that 1 am exempt from the Contracror's License Address
for the following reason (Section 7031,5, Business and �' �
Nrofessians Code): City Tel. No.
❑ I, as owner of the properiy, will do the work and the
sfrudure is nof intended or offered fo� sale (Section
7044, Business and Professions Code). �
CONSTRUC710N LENDING AGENCY
I hereby affirm that there is a construction lending agency for
1he performance of the work for which this permit is issued
(Sec, 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this applimfion and state that the
above information is corred. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize represeniatives of this County to enter upon the
e-mentione roperty for inspection purposes.
-�,,, � SEE REV€RSE FOR EXPLAFIATORY LAP1GiJAGE
� � �d�.��� �--��-��
Signafure of Perm�tee Date