HomeMy WebLinkAbout1579A WORKERS'COMPENSATION DECLARATION � ' I IT
I hereby affirm ihat I have a certificate of conseM to self 20-0026 DPW 6/87
insure, or a cerfificate of Workers' Compensation Insurance, 76A667A
or a certitied copy thereof (Sec. 38oq �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P❑olicy No. .��'J-�Company �%lj�Tc�. �L(af).l7 /,�� � d�7T�
Certified copy is hereby furnished.
aFOR APPLICANT TO FIIL IN(PRIN7 OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS D,`1',. �. �L'.6/yJ j��'�'�i E �� �
tion depariment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
y�J �� WATER CLOSET ������'����� ���
Date Appli4ani NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.�/f;?dry�p�7,�a �/�"J� �✓/�,� '����tit/�'
COMPENSATION INSURANCE SHOWER OWNER � �.'+��d�—�ir��� _�C.�?G�
(This section need not ba completed if 4he work involv�d by �
fhe permif ie for one hundred dollars ($100)or less.) LAVATORY MAIL �/�/ �l�c��� '/
ADDRESS y �C1� .°�j�_ ; /v
I certify fhat in the performance of the work for which ihis
permit is issued, I shall not employ any person in any manner SINK CITY /✓��_ TEL NO �p
c� � ��.`�/� '7/°�l rJ���_.jc9a/
so as to become subjecf to fhe Workers'Compensation Laws. DISHWASHER %
CONTRACTOR� /�`� �� ����� ��.Y
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, afier making this Certificate of ADDRESS `���� � ,�/U��� ��
mption, you should become subject io fhe Workers' SWIMMING POOL RECEPTOR
.npensafion provisions of the Labor Code, you must forth- ��T�«9������ TEL. NO./��
with com I with such rovisions or fhis ermif shall be � LAWN SPRINKLER SYSTEM � C�� (._7 � ��'1✓E�3'
deemed re oked. p p WATER HEATER LICENSE NO. �;�,�r2 -��� CLASS � " ��
LICENSED CONTRACTORS DECLARATION DISTRICT No. �CESSED BY
I hereby affirm that 1 am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS "��/,
(commencing wifh Secfion 7000) of Division 3 of the Business OUTLETSOVER �" ��������'�
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDi4T10N
License Number �z �nlo��c3 Lic. Class ���� DATE —
�—' FINAL
Contractor/—/��k��+j����������Date � � BY
❑ I am�ex��C�d�S��.�A-� ' ���1�s�
B.&P.C. for this reason
Plan check fee
Da9e: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE �� �
Plan check applicant
SINGLE FAMILY
HOME OWNER-BU�LDER DECLARATION Name
�reby affirm ihat I am exempt from the Contractor's License Address
for the following reason (Secfion 7031.5, Business and ,.
rrofessions Code); City Tel. No.
❑ I, as owner of the property, will do ihe work and the `
structure is not infended or offered fo� sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permii is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify fhat I have read this applimtion and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repre°sentafives of this County fo enfer upon the
�meniioned pr-epefity for inspection purposes.
a SEE REVERSE FOR EXPLAPIA'PORY LAPOGUAGE
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Sig ature of Permittee Da1e