HomeMy WebLinkAbout0944A �YORKERS' COMPENSATION DECLARATION I I 1� I I
I hereby affirm that I have a certifimte of consent to self 20-0026 DPW 6/87
insure, or a certifimte of Workers' Compensation Insurance, 76A667A
or a certitied copy eof (Sec. 3800 �ab. C ) COUN7Y OF LOS ANGELES DEPT. OF PUBLIC WORI<S ""
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Policy No. Company �� ��° �-��" `�� ���e�,z /`�.� � ��
� Certified copy is hereby fumished. p
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �y ^�
Certified copy is filed with the county building inspeo- ADDRESS j!£,1 .��.��/���'.`�'�`_8 's'
tionv de ariment. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY f F�, ,,, ,
� � � �� WATER CLOSET � ���� `'� ��-
Daie C Applicant NEAREST ,
� .3
CERTIFICATE OF EXEMPTION FROM WORKERS' BAT.H TUB CROSS ST ,� �':� ,, ;.:rf �tf j� �`"fu��� �_ ,_y-�'<"
COMPENSATION INSURANCE oWNER ,r� ,,,;,.P �---„� "
(This section need not be campleted if 4he work invalved by SHOWER � ,:f /`'� /==�"v ,`�� ��`'_.
the ermit is for one hundred dollars $100 or less. MAII � R�_ . _ ._, �_
P � � � LAVATORY ADDRESS � �iE,`�ks�i�+:r�� '`,,,�r j�t , 9-�� ,r,'.I
I certify that in the performance of fhe work for which this y��
SINK CITY�- ,r TEI. NQ_
permit is issued, I shall not employ any person in any manner � � - � ;�`ry �/j',:%�,;'f �j:j'� Es--�, ��-. .,�
so as to become subjeci fo the Workers'Compensation Laws. DISHWASHER
CONTRACTOR '_- _ . ^ Z. .��,e.
.',>>sz`� �- .''`r"s=; e....�
��te Applicant CLOTHES WASHER
ADDRESS �'� r�_ �. _��.,
TICE TO APPLICANT: If, after making this Certificate of SWIMMINGPOOLRECEPTOR rr�t�f� I` ��'���� �V.`' _
_..emption, you should become subjed to fhe Workers' CITY 'r � TEL. NQ�
Compensation provisions of the Labor Code, you must forfh- LAWN SPRINKLER SYSTEM � ° `'�-��` •` r"°�= l`� -�%'_=j'&_�`
with comply wiih such provisions or this permif shall be s.. ' STATE =,,s /" uC. � �
deemed revoked. WATER HEATER LICENSE NO ; � �� _; ' CLASS _,•�. j
LICENSED CONTRACTORS DECIARATiON DISTRICr No. PROCESSEO BY
GAS SYSTEM OUTLETS �,
I hereby affirm that I am licensed under provisions of Chapter 9 ��� ��'�,f�� �� �y, � _
�,
(commencing with Secfion 7000) of Division 3 of the Business OUTIETSOVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VA�I�ATB�N
� > �t:r, �_;'�u DATE
License Number �t�r- -�- Lic. Class �
FINAL
�`�XE,��`i,, t•"i v �'=%�? -l��aT'�Date f,_ i�� BY
Contractor /
❑ rl'"
I am exempt under Sec. �1�`���
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ � ��� �`� f�
Signature '
TOTAL FEE � �� �_-„��
Plan ched<applicant
SINGLE FAMIIY
HOME OWNER-BUILDER DECLARATION Name
.:reby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel, No.
❑ I, as owner of Ihe property, will do the work and the
sfructure is not intended ur offered for 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 that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and 5fate laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-menti d property for ' s' ction purposes.
��� - SEE REVERSE F6R EXPLi4i�lATORY LAPiGUAGE
��� '�'T ��� „/- M E\j�//„",.I�-�
+tr, .j
Sig ature of Permittee , Date