HomeMy WebLinkAbout0940A WORKERS' COMPENSATION DECLARATION L� � I ��
I'hereby t�ffirm 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 t reof (Sec. 3800 �ab. C.) COUIVTY OF LOS,4NGELES DEPT. OF PUBLIC WORI<S
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P�olicy No. Company �'�� �;����� �- "� �"--'� : ��� �_ ;(�
Certified copy is hereby furnished. �
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUIIDING {`°q,- ,,
Certified copy is filed with fhe couMy buiiding inspec- ADDRESS °� v � '�'�r � � '`�'a•
%, s !. :\i�� � H � a�'.� ,
ti n d artmenf. NUMBER FIXTURE OR ITEM
P @ FEE LOCALITY �r 9 r
C�, . <r"'I e-,''; '�-.� �'o'-�-
Dafe� � � Applicant WATERCLOSET NEAREST p, p � ��
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS SL � �P�` <<� f'p'j e ,rr=t • �'�,_ ��I� ,�
COMPENSATION INSURANCE �?-,_ .
SHOWER OWNER /_ );,a�<i'�i%.�'''''� +�',�!. : "�%,'':�
(This section need not be complef�d if th�work involved by MAIL �
the permi4 is for one hundred dollars (�100)or less.) LAVATORY ADDRESS-�'�%��rl /!ir�.'ct+,i p ?' �l'f'
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY���_�.�,�,� �� qrr r �� TEL.�lO��� ��- �����
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so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR -
_ .,��,�:� 4F<," �,�`€�wi>_ �/�'l,T�
Date App�icant CLOTHES WASHER ADDRESS -- �
TICE TO APPLICANT: If, after making ihis Certificate of SWIMMING POOL RECEPTOR ��1�4 ~ ,Y "`�i�� �1�
empfion, you should become subject to fhe Workers' CITY i'1• - f T�J„N0� ¢-.�t -
Compensation provisions of the Labor Code, you musf forih- � LAWN SPRINKLER SYSTEM '�� �`������'��'�- '?� " � �`�`'`� '
�_, p
with comply with such provisions or fhis permN shall be r� STATE uC.
LICENSE NO.';;'i ��.. %''. CLASS E.j ''��
deemed revoked. WATER HEATER � . ��
LICENSED CONTRACTORS DECLARATION DISTRICT No. PBQCESSED BY
GAS SYSTEM OUTLETS ��f'�, `t
I hereby affirm ihat I om licensed vnder provisions of Chopter 9 � (� a •,� � �^g�-���.�,. ,.y
(commencing with Sedion 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/�L0��T0��j
" � �`,�,J — DATE
License Number°�e �<'-w``4'3 Lic. Cl�ss � 'l�
/-'"t''�'v'� l,Y—v'����,r: .G-��'¢. \ FINAL
Confracfor � ` Dafe .-'��'�"�i`� BY
❑ I am exempt under Sec. .������ �
B.&P.C. for fhis reason �
Plan check fee �; i
Date: ���
PLUMBWG PERMIT ISSUING FEE$ �� �`
Signature
TOTAL FEE � � --, '' � � .�
Plan check applicant ,
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
�
:reby affirm that I am exempt from the Contrador's License Address
Law for the following reason (Section 7031.5, Business and < ,
Professions Code): City Tel. No.
❑ I, as owner of the property, will do ihe work and the
structure is not intended or offered for sale (Section
7044, 8usiness and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that ihere is a consirudion lending agency for
ihe performance of ihe work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read fhis application and state that the
above information is correcf. I agree fo comply with all County
ordinances and Sfafe laws regulating Plumbing, and hereby
autharize repre°senlafives of fhis County to enter upon fhe
above-me ' ed proper y f i spection purposes.
� SEE �EVERS� FOR EXPLAPIATORY LANGUACa�
���/�',"�sr�!�=� ��'fb y��
Signature of Permitiee Date