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Home My WebLink About0929A WORKERS' COMPENSATION DECLARATION � � ` I 'T I he�eby dffirm fhat I have a cerfificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, �ab. C.) COUN7Y OF LOS ANGELES DEPT. OF PUBLIC ONORICS - P�ollcy No��`��'�Company -.5,�,2� ��'�� . � Certified copy is hereby furnished. �� ❑ FOR APPLICANT TO FlLL IN(PRINT OR TYPE) BUILDING � Certified copy is filed with Ihe county building inspec- ADDRESS �� S i,/t/�2f tion dep rfinent. NUMBER FIXTURE OR ITEM @ FEE �QCALITY ` , Date a � � � Applicant WATERCLOSET NEAREST �'Q�� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB cRoss sr. ,C�'�t�pyd .� �t� ��^l COMPENSATION INSURANCE oWNER �,��, • ,.� (This section need not be eompl�4ed if the work invalved by SHowER the permit is for one hundred dotlars($100)or lass.) LAVATORY MAIL +�, ADDRESS ,? / � I certify that in fhe performance of the work for which Ihis permif is issued, I shall not employ any person in any manner SINK CITY��, ��,�, r � so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR �� ! i` G Q Date Applicant CLOTHES WASHER ADDRESS / �TICE TO APPLICANT: If, pfter making lhis CeHificate of SWIMMING POOL RECEPTOR r��l �4 � mption, you should become subjed to the Workers' CITY � T N Compensation provisions of the Labor Code, you must forih- �AWN SPRINKLER SYSTEM �` --�� ' �'�"`� with comply with such provisions or this permit shal) be 4''? STATE , LIC. deemed revoked. WATER HEATER LICENSE NO.� - CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROC�`D BY I hereby affirm fhat I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS h �,a� ��g �-e,� ,,, (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER a ` �'��""'h'"" and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL !le4LlDATlOR! �,��7 DATE License Number�� Lic. Class �� I�t/�J/ �'�'�lL��' ��t/C. FINAL �CoMractor ( Date��7�� BY ❑ I am exempf under Sec. B.&P.C. for this reason Plan check fee Dafe: _ PLUMBING PERMIT ISSUING FEE$ ��-> -�� Signature TOTAL FEE : h Plan check applicani SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name reby affirm thaf I am exempt from�he Contractor's License Address +i �.,w for fhe following reason (Section 7031.5, Business and " Professions Code): City Tei. No. ❑ I, as owner of the property, will do the work and the sirucfure is not intended or offered for sale (Section � � c 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm ihat�here 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 fhis application and state fhai the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize repre`sentafives of ihis Counfy to enler upon the above-mentione rty for ins cti urposes. - SEE RE�/ERS� FOR EXPLi4NATORY L�4PIGUAGE � .�.�<.� �`=J��,� 'Signature of Permittee �� Dafe