HomeMy WebLinkAbout0943A WORKERS'COMPENSATION DECLARATION � ' L ' �T
1'hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a cerfificafe of Workers' Compensation Insurance, 76A667A
or a r tie opy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORI<S
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Paolicy No. Company `-�.'��t� �:.�aJ r"<:� 1�,� NF_ . / , �,1
Certified copy is hereby furnished. `'
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the counfy building inspeo- ADDRESS `����"� �, �.(� �,(,*f'-=�!P `_'."
tio de ❑rtment. NUMBER FIXTURE OR ITEM @ FEE
P�� LOCALITY � �e
WATER CLOSET � ��' t �����'� �����`
Date l � Applicant NEAREST , ,;
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST /�-'�� +,�.�. � F��� '�+���I�-='�&''''� �°�` ''_f�d��-�-�
COMPENSATION INSURANCE SHOWeR oWNER s,<,�,����s�_ r�,�� -=--y��
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(This section need not b�comple4ed if fhe wor&involved by MAIL
fhe permit is Foe one hundred dollars ($100)or less.) LAVATORY ADDRESS ��� � ��3'+�'F%;�f; �fV��a �,;;t'�,`''�
I certify that in the performance of the work for which this �
ermif is issued, I shal)not em lo an erson in an manner SINK CITY yr ,�� �,,-,rG.,,� TEL NO �,�- � ������� ,
P P Y Y P Y r ,_� � � l`�_ti �r�
so as fo become subject to the Workers'CompensaTion Laws. DISHWASHER
CONTRACTOR=" � 4 t
'�=� �<�-,f-4�,,.- ,G f- .r :f.r`a.'�y�"��_- y�-i.�r'�� ���
��te Applicant CLOTHES WASHER
TICE TO APPLICANT: If, after making this Certifica�e of ADDRESS �� ,��;� ,�:���.,���s,� j��YT.
.,,em fion, ou should become sub'ect to the Workers' SWIMMING POOL RECEPTOR �
P Y I CITY�� «=J`- �' TEL. NO.= i �
Compensation provisions of the Labor Code, you must forfh- r �AWN SPRINKLER SYSTEM J`�y - v�� `���`' �"}f��F`'� `
with comply wifh such provisions or this permit shall be � � STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. _��,°e;�i;f:.�f,_ CIASS i�"`��
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm thaf I am licensed under provisions of Chapter 9 GAS SYSTEM OUT�ETS ,\�, , �ti
�` t (' �j�, C';.��� �.;�
(commencing with Section 7000) of Division 3 of ihe Business OUTlETS OVER _
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �d41,I[��'r��[�
¢ DATE
License Number �-����%�-��-'= Lla Class t�-�.�y
FINAL
i`�e rr,�a,v'�� fz�y a�-Ci�-��;° � Date ,-t'_.'�'e",�r� x"= BY
Confractor t��
� '�, 4 � t�l�'��
I am exempf under Sec.
B.BP.C. for fhis reason
Plan check fee
Dafe:
PLUMBING PERMIT ISSUING FEE$ � � ��"y
Signature
TOTAL FEE �,� "`=e.��
Plan check applicant
� SINGLE FAMILY � � � � � �
HOME OWNER-BUILDER DECLARATION Name
zreby affirm that�am exempt from the Contractor's License Address �
Law for fhe following reason (Secfion 7031.5, Business and
i
Professions Code): City Tel. No. �
❑ I, as owner of the property, will do ihe work and }he
structure is not iMended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consfruction 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 cerfify that I have read fhis application and state Ihat ihe
above information is correct. I agree lo comply with all County
ordinances and Stafe laws regulating Plumbing, and hereby
autharize represenfatives of ihis County to enter upon the
above-�necJ propert fo i ection purpases.
� " / SE� REVERS� F�R EXPLAN,4TOIiY LANGUAGE
,�..�!. �� .. t�t�_16 � ���(�j
Slgnature of Permittee '" Daie