HomeMy WebLinkAbout0942A WORKERS'COMPENSATION DECLARATION I �' I IT
� hereby uffirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORICS
a�y N�S���`�ompany �''��`�' t ti�-at�� F. :-�,�.—,�' /��.�" " _ "'.'�
Cerfified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) i,�
Certified copy is filed with the munty building inspec- ADDRESS ����. �� -jl��!';�f�'7:�`PC' �'i�`,
NUMBER FIXTURE OR ITEM @ FEE
t�on d��rimen�. LOCALITY �y �_J � _ �r � � ,
��; ! �r' WATER CLOSET
Date Applicani NEAREST �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST ��` f�-r-- ��! } �'<,.:_ _ �;>/ �r _� / �, --v'%�
COMPENSATIONINSURANCE OWNER �y�y�.,� ^t_� ���,r-�� ,-r--,�s�_
SHOWER �_ __
(This section need nof b�eompleted if the work involved by MAIL
the permit is for one huadred dollars ($100)or less.) LAVATORY ADDRESS �/,'� ✓�j�� =•�/f� '°l� %�•`� `, �`_ T`==-f'`'�'
I certify that in the performance of the work for which this �
P P Y Y P Y SWK CITY�� ��'�-;-t,qsy TEL NO.���_ �� i,. ,,��_ �
ermit is issued, I shall not em lo an erson in an manner ���-�� �
so as fo become subjecf to the Workers'Compensation Laws. DISHWASHER _
CONTRACTOR �r:;,j„�;�4 '� i<�`t'�-t�"��a' .��r�'i�,
Date Applicant CLOTHES WASHER
1TICE TO APPLICANT: If, after making this Certificate of ADDRESS f��?� r�� r�i �?`�'S''�/ir> �'7/�:_
amption, you should become subjecf to ihe Workers' SWIMMING POOL RECEPTOR
CITY �'_
Compensation provisions of the Labor Code, you must forih- i �AWN SPRINKLER SYSTEM � � � �"'� �t'�J " �� ��f� `=`y���
with comply with such provisions or this permit shall be � � STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. �"�, %-P�_,'^:�'r,_ CLASS �������;
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR�CESSED BY
GAS SYSTEM OUTLETS �
I hereby affirm fhat I am licensed under provisions of Chapter 9 � y�., � ;;
c_� . ��«���,� =�
(commencing with Section 7000) of Division 3 of fhe Business oUTIETS oVER _
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
DATE �✓��B�ATI�fd
_� � � rq,✓9
License Number a����k= Lic. Class
FINAL
��s,,�°c�'`•4��" < `�`���;� �" .:�=��;i`j� BY
Coniracfor� ate
❑ I am exempt under Sec. � f h��'�
B.$P.C. for this reason
Plan check fee
Daie: p�UMBING PERMIT ISSUING FEE$ ��� ���
Signature
TOTAL FEE ��,�� �� �
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
ereby affirm that I am exempt from the Contractor's License Address �
Law for fhe following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of the property, will do ihe work and the f i �
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDWG AGENCY'
I hereby affirm that there is a construction lending agency for �
the performance of the work for which fhis permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read Ihis application and state that ihe
above informaiion is corred. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above menti e�roperty for insgection purposes.
i SEE REVERS� FOR EXPLANATORY LANGUAGE
.o'� �� �����'J„�:�� �y� ��'
Signature of Permittee Date