HomeMy WebLinkAbout0931A WORKERS' COMPENSATION DECLARATION � TI L I I
i' hereby 6ffirm that I have a cerfificafe of consent fo self 20-0026 DPW 6/87
insure, or a certifimte of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS AnlGELES DEPT. OF PUBLIC WQRI<S
Policy No���� Company_rS� � �'�'�
� Certified copy is hereby furnished. ��J �� �
� FOR APPIICANT TO FILL IN(PRINT OR TYPE) BUILDING � C 'E V ��l Q
Cerfified copy is filed with the county building inspec- ADDRESS J
fipn'de-ar1 ent. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY ' o ��,� �
Date � � Applicanl WATER CLOSET NEAREST -/
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUe CROSS ST. j'.�/1��r°•�� �'� ��'�'�[CC /�I.,�
COMPENSATION INSURANCE SHOWER OWNER ��.3..��� ��� �
(This sec4ion need noP 6e comple4ed i6 fh�work irvvolved by MAII .�,�/
the permit is for one hurvdred dollars (�100)or less.� LAVATORY ADDRESS � �J( i—/ l�. � �
I certify fhat in the performance of the work for which ihis
permit is issued, I shall not employ any person in any manner SINK CITY ��� ���,9 1 . �3�-�. �
so as to become subject to the Workers'Compensation Laws, DISHWASHER
CONTRACTOR ������ L �5�,9 �
Date Applicant CLOTHES�NASHER
`1TICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR ADDRESS j � ��,e
;mption, you should become subjed to the Workers'
Compensation provisions of the Labor Code, you must forth- CITY ; �,�U �N_ , �
IAWN SPRINKLER SYSTEM ��
with comply with such provisions or fhis permil shall be � STATE 2� LIC.
deemed revoked. WATER HEATER LICENSE NO..�.J� ��j CIASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO�SSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �.
� � �����.�-�
(commencing with Section 7000)of Division 3 of ihe Business OUTlET50VER -�
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL b�L9DATl01d
License N�mber � DATE
a���Lic. Class �."��
�C,g 1,��(�f.4� C��l'C2l..CC��£��+ 9 FINAL
CoMracfo \ Date �����/ B��
❑ I am exempt under Sec.
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ �`';. ���
Signature �
TOTAL FEE ' � `��;�
Plan check applimnt
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
�reby affirm thal I am exempt from the Contractor's License Address
ww for fhe following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of ihe property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code). �
CONSTRUCTION LENDING AGENCY � �
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued t "� �" € ��.�"� �i
(Sec. 3097, Civ. C.).
Lender's Name
�� <� -
�;. � � ��
Lender's Address
I certify that I have read this application and state that fhe
above information is mrrect. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize repre°sentatives of this County ro enter upon fhe
above-mentione roperty r i purposes.
SEE �EVERS� FOR EXPLAIVATORY �AhJC3UAGE
�^�.�c��
Signature of Perrriittee Date