HomeMy WebLinkAbout0941A WOR ERS'COMPENSATION DECLARATION ' TI L I � IT
I hereby�ffi m that I have a certifimte of consenf to self 20-0026 DPW 6/87
insure, or a cerhficaie of Workers' Compensation Insurance, 76A667A
or a cer�itied copy thereof (Sec. 3800 �ab. C ) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P
�S���P-�S� Company �if:''`i .� l"'����t� �,i�'f�"1 r--' �'_f`:. ..g ,- y
Certified copy is hereby fumished. BUILDING i;�
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRE55
Certified copy is filed with the county building inspeo- ��-� � ��������%��� ����
tio de arimenf. NUMBER FIXTURE OR ITEM @ FEE
� � LOCAIITY �`�v�,��r`��`' '"�; f.�`'�
WATER CLOSET
Date � � � � Applicanf NEAREST �, ��� � ,_
� BATNTUB CROSSST __li��� +.r',si',i „!;�.�r � � �-•,_`�_ c�',_,
CERTIFICATE OF EXEMPTION FROM WORKERS'
�
COMPENSATION INSURANCE OWNER �,�,��r � � ,!
(This section need not be comple4ed if 4he work involved by SHOWER -�` �f=-` t � �' "=r _ _
the ermi4 is for one hundeed dollars 100 or less. MA�L > -'" /'.,'.;� ; � '�,�Y`
P �� J � LAVATORY ADDRESS , 1:_i .�r�� { f`,"'fy°; ,'
I certity that in the performance of the work for which this �
SINK CITY TEL.,N �m
permit is issued, I shall nof employ any person in any manner i"' 6j �Y `,� r ?�s q ,°i'�;.';;'
so as to become subject to the Workers Compensafion Laws. DISHWASHER � �
CONTRACTOR -
,1'-%.i:�,av�il"�- •E.�}:-jI 'j v�'9&
Date Applicant CLOTHES WASHER ADDRESS " ' �
TICE TO APPLICANT: If, afier making this CertificaTe of � `� �/� I/` � ��/�=� "�`'� �`��'
:mption, you should become subject to ihe Workers' SWIMMING POOL RECEPTOR ,
CITY
Compensation provisions of the Labor Code, you must forfh- � LAWNSPRINKLER SYSTEM � 7,'<'; ,� ,'.'_ _ TEL-?1y0� _t�',�� .}
with comply with such provisions or this permit shall be '�a STATE uC. p
deemed revoked. WATERHEATER LICENSE NO --��y� ��,^i,�� CLASS � -wt��
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR SSED eY
GAS SYSTEM OUTLETS � �'
I hereby affirm that I am licensed under provisions of Chapter 9 (� �, ,�'`� t''��"� ��..,
(commencing wifh Section 7000) of Division 3 of the Business OUTLETS OVER � �`-`'"`Y� �� `'-''�
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL \/��0���0��
� DATE
"7��=L� , �1 ` �'.�i
License Number -�- �_Lic. Cluss
+!�`��.r��, / dt�r�K�P�'+✓r; t�':_= FINAL
C�ontractor ''�� �Dafe.���� !�e�` BY
❑ � , �
I am exempt under Sec. � �
B.&P,C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ � ��'��
Signature
TOTAL FEE �� � yQ
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name '
:reby affirm that I am exempt fram the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): Ciry Tel. No. �. '
❑ I, as owner of the properry, will do the work and the
sfructure is not intended or offered for sale (Sedion
7044, Business and Professions Code).
CONSTRUC710N LENDING AGENCY
I hereby affirm that there is a construdion 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 thal the
above information is correct. I agree to comply with all County
ordinances and 5tate laws regulating Plumbing, ond hereby
authorize repre°sentatives of this County to enter upon the
above-mentioned property f r i ecfion purposes.
�� r � SEE REVERSE FOR EXPLANATORY LAIVtiUAGE
�'�� �
�i �- �.--�� /---'���,f� -:v%�=
Signature of Permittee Date