HomeMy WebLinkAbout0937A WORKERS'COMPENSATION DECLARATION L' TI I IT
� hereby dffirm that 1 have a certificate of consenf to self 20-0026 DPW 6/87
insure, or a ceriifimte of Workers' Compensalion Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORI<S
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p❑olicy No '�=ei�'� _�Company���% �%S`'`�'j�,� C y _.��. ,� .'' te! i
Certified copy is hereby fumished. c-- ; f f
� F O R A P P L I C A N T T O F I L L I N(P R I N T O R T Y P E) B U I L D I N G ��,,Y;,�� ,. , _ ,, �
Cerfified copy is filed with the county building inspec- ADDRESS �'r ,-.�/,�;-'«-�`r .7 ��;
t'o d pariment. NUMBER FIXTURE OR ITEM a FEE �OCALITY j};�._ '
�:� . '+ ; `-e- s� � ��
Date � . a Applicant WATER CLOSET NEAREST - i
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRoss ST /� ,`�r�'j yyy� i��% �!,'N-S-r�+f" `,�` �Sl",s#��?i
COMPENSATION INSURANCE SHOWER OWNER �%��,,,��,,,�,��� ;��,�_ �
(This secfion need no}be comple4�d if fhe work involved by ��'
the ermit is for one hundred dollars g100 or less. MAIL d_ rz �
p ( � J LAVATORY ADDRESS _' �� ' /;-�;.�_i�'�^�r' ' �"�T'
I certify that in the performance of the work for which fhis � �
SINK CITY � i TE. NO
permit is issued, I shall not employ any person in any manner , '�-'�� :�f=� ,w_ ,� - �s,—,. ��� ,�
so as to become subject to the Workers Compensation Laws, DISHWASHER y�
CONTRACTOR
._rfj F"�i!;"`,�a ���Atr_J�.,,r � - =�l�¢ ,
Date ApplicaM CLOTHES WASHER
ADDRE55 �� � ��a C'
7TICE TO APPLICANT: If, afier making this Certificate of /:-� �'' /J��'`�°%/f✓✓�7` t/��
:mption, you should become subject fo ihe Workers' SWIMMING POOL RECEPTOR f
CITY � , ✓� ;7,��i�fJO.-�a-r r s 4=.
C�mpensafion provisions of ihe LaSor Code, you must forfh- j LAWN SPRINK�ER SYSTEM � �' `' '�"� `"
with comply with such provisions or this permit shall be � - `' STATE LIC.
deemed revoked. WATER HEATER � LICENSE NO. ;.-L;��%-�� L� CLASS �_�_-L '
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ' {� `
�.�`� ��ti ��¢� �-._, �._-_�
(commencing with Secfion 7000) of Division 3 of fhe Business OUTLETS OVER -
and Professions Code, and my license is in full force and etfect. 5 PER SYSTEM FINAL ������T���
License Number �`����.��'�ff�Lic. Class �"-��' DATE
��,�a�a�;jt��r l��'dr_/��`�;^: �='�� s FIPVAL
C ntracfor Dtrfe-�s'����"��r:�` BY
❑ I am exempt under Sec. �'a � � t� ���(
�T
B.&P.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature �"�� �`�
TOTAL FEE - % �", �� j
Plan check applicant � �
SINGIE FAMILY
HOME OWNER-BUILDER DECLARATION Name
�reby affirm that I am exempt from the Contractor's License Address
�aw for the following reason (Sedion 7031.5, Business and •
Professions Code): City Tel. No,
❑ I, as owner of the property, will do the work and the
sfructure is not infended or offered for sale (Section ; - � ,,� ,,
7044, Business and Professions Code).
CONSTRUC710N LENDING AGENCY
I hereby affirm that there is a construction 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 applicaiion and state that the
above intormation is correcl. I agree fo comply with all County
ordinances and 51ate laws regulating Plumbing, and hereby
authorize representatives of this Coumy to enter upon the
above-menhp oper f -inspedion purposes.
SEE R€VERSE FOR EX�LAIVATORY L�4P7GUAGE
�� 3 i'! .�/� �'i%
� Signature of Permiftee Date