HomeMy WebLinkAbout0936A WORKERS' COMPENSATION DECLARATION I I I IT
I'hereby a#firm thaf I have a cerfificate of conseM to self 20-0026 DPW 6/S7
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS AIVGELES DEPT. OF PU�LIC WORKS
P�olicy No.����'"C'or`iipany�17`��L`.� / �r�t�C] �� - _ �, �
Certified copy is hereby fumished. ���~�� ' � .� r '(���
� FOR APPLICANT TO FILL IN PRINT OR TYPE BUILDING ,a� �, _ �_l,
( ) ; i ,:��s,�r
Certified copy is filed with Ihe county building inspec- ADDRESS '�`��,� �j ,_�;.w,. _� �k.,_�
tio e arimenf. NUMBER FIXTUREORITEM @ FEE
P LOCALITY q 1�,'�;'�p;�r,,, �r
� WATER CLOSET
Date � �� Appli4ant NEAREST
CERTIFICATE Of EXEMPTIQN FROM WORKERS' BATN TUB CROSS 5T��i'-`�tir�:_ �' �_1. " � r;�;,-,', � �?"�jt��/'�!--��,- �
COMPENSATION INSURANCE
(Yhl:t�ction neod rro4 b�eomple4�d if ih�work Involv�d by SHOWER OWNER -,��,�. .-�� .;�,� �_l .y;�.
4he permtt la for one hundr�d dollars (�100)or less,) LAVATORY MAIL �„ �
ADDRESS �.°��;,: .i �%;'�_�V{ '> z�_
1 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 j r. � � �.-.�:,� � �� �,
so as to become subject to the Workers'Compensafion Lpws. DISHWASHER H
CONTRACTOR�, �'�„ �5 _
_.�,� ��>� /�.- a��
Dafe Applicant CLOTHES WASHER � �
ADDRESS / �. � �y�
TICE TO APPLICANT; If, after making this Certificate of SWIMMING POOL RECEPTOR � �� �� - ������ � Q
mpfion, you should become subjecf to the Workers' r 1
Compensa}ion provisions of the Labor Code, you must forih- LAWN SPRINKLER SYSTEM _\ � CITY �'� �,�`',,�� TEL. N :��:����_f�
/
with comply with such provisions or this permit shall be � -- STATE uC. � �>
deemed revoked. � WATER HEATER LICENSE NO. `y Q�:�� CLASS �� <
UCENSED CONTRACTORS DECLARATION DISTRICT NQ PRO ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS � �F � �`�,
�Q'`_ � F� `-�,�_€'...,s...._�w
(commencing with Secfion 7000) of Division 3 of fhe Business OUTLETS OVER _
and Professions Code,and my license is in full force and effed. 5 PER SYSTEM FINAL �ALO��'�0��
DATE
License Numbery��_�� Lic. Class�•�� �
�J�t�''��''���Ci�.`9� �-�' :� K��,� BY AL
CoMractor Date �"��
A-�c.
�
❑ I am exempt under Sec. ��I i ''� °-.H �
e
B.&P.C. for this reason
Plan check fee
Date: tl . �
PLUMBING PERMIT ISSUING FEE$ g
Signature
TOTAL FEE �� �" �
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
reby affirm that I am exempt from the Coniractor's License Address �
ww for 4he following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section � , � �
7044, Business and Professions Code).
CONSTRUCTION IENDING AGENCY -
I hereby affirm that there is a consfrudion lending agency for
the performance of ihe work for which Ihis permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this applimtion and state fhat fhe
above information is correct. I agree to comply with all County
ordinances and State laws regulafing Plumbing, and hereby
authorize repre°sentatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLOafd,4�ORY LAfVGU�4GE
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Sign�Permittee Date