HomeMy WebLinkAbout0939A WORKERS'COMPENSATION DECLARATION L' °r� � L ' '
I'-hereby Gffirm ihat I have a cerfificate of consen� to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy ihereof (Sec. 3800, �ab C.) , COUN1'1�OF LOS ANGELES DEPT. OF PUBLIC WORI<S `"`
'�S����-�5'3�' �,�;�, '-
Policy No. Company �E��_��1''t('f � rsh �-'�.: : �,f✓ > _ _ ,; .�
� Certified copy is hereby furnished. A
� FOR APPLICANT TO FILL W(PRINT OR TYPE) BUILDING �; ,�, � � a„
Certified copy is filed with the county building inspeo- ADDRESS .a;�'__: :� `�;/_y;'_:" ;?:�
ti n de art ent. NUMBER FIXTURE OR ITEM @ FEE
e� q � LOCALITY p�� �/ � � �f ���.
Dafe ° p �-'� Applicant WATER CLOSET NEAREST �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CRoss ST L,������� '� •za`; �q��1�� �°+;;�}�+j >- ;_�,!��'*�r�,����'_
COMPENSATION INSURANCE OWNER .�,�;,�. ._
(7his section ne�d nof be comple4�d if the work involved by SHOWER �r-<- �/ ��y'� �'��� � `����ti' _
MAIL
4he permit is for one hundred dollars ($100}or less.) LAVATORY ADDRESS-��-? ' i `3"'_irV'�' '�k'-`'-`
I certify that in the performance of the work for which this v
ermit is issued, I shall not em lo an erson in an manner SINK CITY�; �F �
P P Y Y P Y � •-��� ,�/�:�*ra TEL.� j „� ;
so as to become subject to the Workers'Compensation Laws. � 5 �
DISHWASHER CONTRACTOR -
-r�, `'Y"c i' �/�'`� ey�.�'t �t� �i'tir
Date Applicant CLOTHES WASHER ADDRESS ' ; € lF* - � ,�/;��
TICE TO APPLICANT: If, afler making this Certificate of SWIMMING POOL RECEPTOR �� �'f��������� ��
mpfion, you should become subject to fhe Workers' CITY '✓ t•. ,- " ,T �NO.----1; -
Compensatio� provisions of the Labor Code, you musf forfh- � LAWN SPRINKLER SYSTEM � �� ����``���'��`�'` ' � ^ �`�`_�
with comply with such provisions or this permit shall be 4.``s STATE � CI . �.�_
deemed revoked. WATER HEATER LICENSE NO. ����" -.",y,; -, CIASS N--�%'
L�CENSED CONTRACTORS DECLARATION DISTRICT NO. PRO��SSED BY
GAS SYSTEM OUTLETS � -°t �
I hereby affirm that I am licensed under provisions of Chapter 9 I �� ' ��\ � `�\ cs�,, �
(commencing with Secfion 7000) of Division 3 of the Business OUTLETS OVER C .�
and Professions Code,and my(icense is in full force and effect. 5 PER SYSTEM FINAL �pp����0,gs�§�
License Number DATE
YA`�Y i-._`-.`�:, LIC. CIQSS ��F'-�+:�
-f - FINAL
e��,tt�, ��t'� �' ' �'`�"r a:-�..��a µ BY
C ntracfor � .� � `�^r�{ Dafe --�°P"`P� u �"�
❑ ��
I am exempt under Sec. ,��� d-� �� i`� �
3.
B.&P.C, for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ ��� ��
Signafure
TOTAL FEE � �;, ��
Plan check applicant
SINGLE FAMILY �, �
HOME OWNER-BUILDER DECLARATION Name
reby affirm that I am exempf from the CoMractor's License Address '
Law for fhe following reason (Section 7031.5, Business and
Professions Code): City Tel. No. j
❑ I, as owner of the property, will do ihe work and the
sfruciure is not intended or offered fo� sale (Secfion
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 certify that I have read this applicafion and state lhat the
above information is correct. I agree lo comply with al)County
ordinances and State laws regulaling Plumbing, and hereby
authorize repre°sentatives of this County to enter upon the
above-mentionedl roperty for insp c npurposes.
�� P �,.-/_ -= SEE REVERSE FOR EXPLdBMATORY LAPiGUAC9E
,�= �- �>i� ,-—� ���"'� �,;-�
Signature of Permi{tee Daie