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Home My WebLink About0935A WORKERS' COMPENSATION DECLARATION I TI L I E I I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 ' s insure, or a cerfificate of Workers' Compensation Insurance, 76A667A o� a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No�. ��1��^_e��a�Y.a�'��-'��` ��/1�� / a Certified copy is hereby furnished. ��7� ` ` � ^ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING LJ Certified copy is filed with the county building inspec- ADDRESS ��S�� tion de riment. NUMBER FIXTURE OR ITEM @ FEE � � � p�� LOCAUTY ��, 4' WATER CLOSET Date � � ApplicaM NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BArH TUB CROSS ST. � s�.CJ ��V� COMPENSATION INSURANCE OWNER � � (This sec4iors�eed not 6e comple4ed iF th�work involved by SHOWER ��C"Y"•�L�.� �i�� the ermit is for one hundred dallaes 100 or less. MAIL p (S ) � LAVATORY ADDRESS�f�� L . �, I cerfify that in the performance of the work for which this _ � A permit is issuecl, I shall not employ ony person in any manner SINK CITY � �� ,�,r� TE so as to become subject to the Workers Compensation Laws. DISHWASNER � CONTRACTOR � s9��,�-� � J. � �� Date Applicant CIOTHES WASHER ADDRESS '�TICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR �� •� emption, you should become subject fo the Workers' CITY /�� ' TE�. NO. Compensation provisions of the Labor Code, you must forth- /�;>1` '�" ��-�� LAWN SPRINKLER SYSTEM with comply wifh such provisions or this permif shall be t"�� "'"'STATE LIC. deemed revoked. WATER HEATER LICENSE NO. 3� �- CLASS C'� LICENSED CON7RACTORS DECLARATION DISTRIC7 No. P�CESSED BY I hereby affirm that I am licensed under provisions of Chapfer 9 GAS SYSTEM OUTLETS �� 'a�p�'� �� a c-��.. 4w (commencing with Secfion 7000) of Division 3 of ihe Business OUT�ETS OVER - -�v,,.,. and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ��,LID�TA�� License N�mber - DATE ��i �Lic. Class� ��4�iCl.�!'.,,o .��i�� ` e e � FINAL Contrador � �ate /'t`�" BY ❑ I am exempt under Sec. � / 1 �� 9 �� . B.&P.C. for this reason Pian chetk fee Dafe: — PLUMBING PERMIT ISSUING FEE$ y;�� Signature TOTAL FF.E �� Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name ereby 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, os owner of the property, will do the work and the strucfure is not intended or offered fo� sale (Section 7044, Business and Professions Code). ' CONSTRUC710N LENDING AGENCY I hereby affirm that fhere is a construdion lending agency for the performance of Yhe work for which this permit is issued (Sec. 3097, Civ. C,}. Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all CouMy ordinances and 5tate laws regulating Plumbing, and hereby authorize repre°sentatives of this County to enter upon the above-mentioned property for inspec�ion purposes. SEE �EVERSE FOR EXPLAPlATORY LAPI�UAGE � �� , .<. � Signature of Permittee~ Date