HomeMy WebLinkAbout0938A WORKERS' COMPENSATION DECLARATION � T I L I I
i hereby affirm fhat I have a certificafe of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensaiion Insurance, 76A667A
ar a certified copy thereof Sec. 3800 Lab. C )
� � COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
Policy No�i`�-T.,ti�t.y' �ompany �.��=i�7�„�1:�;�'��;i � � _; �!�i �`•� _ �'�y
� Cerlified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING + 1 t^ 4� , ���
Cerfified copy is filed with the county building inspeo- ADDRE55 _;�� `_,, ' ``<� ,(
d parlmenL NUMBER FIXTURE OR ITEM @ FEE �OCALITY "t�•
g ��i-. �.� (!_-. r
Date g � Appli4ant WATER CLOSET NEAREST L i' .fi
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST ��°'�� y� :� �='�'f�c•��';j f i�`�' .�9,�jr�'
,
COMPENSATION INSURANCE OWNER a��-
SHOWER ,-`•,,;;yc=��.Nl:..,Ay � �. j :�ti..:
(Thic secHon need no4 be completed ff 4he work involv�d by - �
4he ermk fs for one hundred �follars $100 or less. MAIt r , f,
P � � � LAVATORY ADDRESS � '�` " i ?,� � '
: /` ' d' � �—
I certify fhaf in fhe performance of the work for which this
permit is issued, I shall nof employ any person in any manner SINK CITY�- ,��j syJ� �� � 'mLE�.,_� ��E:�„� „z w_ {�
so as to become subjecf io the Workers'Compensation Laws. ' �
DISHWASHER CONTRACTOR �_� �,
✓, i-`V'�".^ �sY 'Z `�..:, �(e.�
Date Applicant CLOTHES WASHER ADDRESS
TICE TO APPIICANT: If, after making this Certificate of -%�' "-%%"';'��'�eti-.:`i `F��
mption, you should become subject to fhe Workers' SWIMMING POOL RECEPTOR .
CITY : - TE-��I .
Com ensation rovisions of the Labor Code, ou must forth- ) - ' ��`�''-`�
P P Y LAWN SPRINKLER SYSTEM ° "�'� \i'� � ✓� �r �"-' '�
with comply with such provisions or ihis permit shall be 1 �:� ���STATE , . LIC. ,�,r�v��
deemed revoked. WATER HEATER LICENSE NQ �_', ',/�k.-.�``- CLASS < -;
LICENSED CONTRACTORS DECLARATION �isrRicr No. � PRO�ESSED BY
I hereby affirm fhaf I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ��_`� �`��1-� �� � y
� �� _�_.-
(commencing with Secfion 7000) of Division 3 of ihe Business OUTIETS OVER —
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �,l�<O�A�'0��
; . ,--,.:,---
DATE
License Number � '�,��•-'=>>^� Lic. Class � "'
/'-��,.�e''� ' ��-,,�� ��_: ` ,�.V� ��X ,��,_ BIYAL
Contracto� �� Date'
❑ � � `��'d
I am exempt under Sec. � " � �
t
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ �`� ��i
Signature
TOTAL FEE "� �-_�; �'�
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUIIDER DECLARATION Name
reby affirm that I am exempt from the Contractor's License Address
�uw for the following reason (Seciion 7031.5, Business and
Professio�s Code): City Tel. No. ` f
❑ I, as owner of ihe property, will do the work and ihe r � '� �� G. �'� �'
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a conslruction lending agency for
the performance of ihe work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify Ihat I have read ihis application and slale that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repre`sentatives of this County to enter upon the
above-mentioned property for inspection purposes.
��� �'j�'�'=' j � = ry SEE REVERS� POR EXPLAPdla70RY Le4iVGUP,GE
�„"'r�`�r/�g � ��.% %��--�;=,-
Signature o ermitte�"��T Date