HomeMy WebLinkAbout0930A WORKERS'COMPENSATION DECLARATIOfV ' ' F L I IT
1 hereby dffirm that I have a cer�ificate of consent to self 20-0026 DPW 6/87
insure, or a cerfificafe of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Polic�l�'"a���`—�Company�"�!'T� 1�"C7N��' ���L� .O � �
� Certified copy is hereby furnished.
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING`„ ,,� �� �
Certified copy is filed with ihe county building inspeo- ADDRESS S', 1l'
ti d parimenL NUMBER FIXTURE OR ITEM @ FEE LOCALITY �
� WATER CLOSET ������
Date � � � Applicant NEAREST r '/
CERTIFICATE OF EXEMPTION FROM WORKERS'
BAT,H TUB CROSS 5T.���'J�.�(' � ��i'1[Cz
COMPENSATION INSURANCE SHowER OWNER � ��� ' �-
(This section need nat be coenpl�t�d if the work iervolved by
fhe permit is for one hundred dollars ($100)ar less.) LAVATORY ADDRESS 31�/� T�('E/��)
1 certify that in the performance of the work for which this
permii is issued, I shall not employ any person in any manner SINK CITY �� � � /N �_ �,�Q
so as to become subject to the Workers Compensation Laws. DISHWASHER
CONTRACTOR r ���,�s�� �,!
Date Applicant CLOTHES WASHER ADDRESS
7TICE TO APPLICANT: If, afier making this Certificate of � t�
:mption, you should become subjecf to the Workers' SWIMMING POOL RECEPTOR
Compensafion provisions of the Labor Code, you musi forih- LAWN SPRINKLER SYSTEM i,� µ CITY � � �Q 11 ��T NO. �� _
G�_
with comply with such provisions or ihis permit shall be � STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. � CLASS '�
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROC SSED BY
I hereb affirm thaf I am licensed under rovisions of Cha ter 9 GAS SYSTEM OUTLETS � � �'^ y
Y P P ��� � 9 �,('`_P_y�.�''��,�__'^"_
(commendng with Secfion 7000) of Division 3 of fhe Business OUTIETSOVER � - ---
and Professions Code, and my license is in full force and effed. 5 PER SYSTEM FINAL \/��I���6��y
�^ DATE
License Numbec�e�F�lic. Clas���
Cy ��elA� tizK�`S� � �5�,�'—�� FINAL
�ractor � � Date BY
❑ I am exempt under Sec.
8.$P.C. for this reason Plan check fee
Date: pLUMBING PERMIT ISSUING FEE$ �� ���
Signature
TOTAL FEE ��� �� � �
Plan check applicant
SINGLE FANIILY
HOME OWNER-BUILDER DECLARATION Name
reby affirm that I am exempt from the Contractor's License Address
��w for ihe following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
sfruct�re 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
(Sec, 3097, Civ, C.).
< <; , r
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 County
ordinances and 5tate laws regulating Plumbing, ond hereby
authorize repres atives of this County to eMer upon the
above-me ' p operty for ' spection purposes.
_ SEE REVERSE FOR EXPLA�I,4TORY LAIVGU.4GE
� ������'
Signature of Permitt e Date