HomeMy WebLinkAbout0922A WORKERS' COMPENSATION DECLARATION `I � L � IT
� I-h�reby affirm �hat I have a certificate of consenf to self 20-0026 DPW 6/87 ��� �
insure, or a cerfificate of Workers' Compensafion Insurance, 76A667A
or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OIF LOS ANGELES DEPT. OF PUBLIC VIIORICS
7����- �� �"�
P❑olicy No. Company�'��.,��'�=� � �'�
Certified copy is hereby furnished. `5 ��
� FOR APPLICANT TO RLL IN(PRWT OR TYPE) BUILDING �
Certified copy is filed with the county building inspec- ADDRESS �/ �'„ ���,`/���
� n�epartme t. NUMBER FIXTURE OR ITEM @ PEE LOCALITY
WATER CLOSET ������� ����'
Date � Applicant NEAREST
CERT FICATE OF EXEMPTION FROM WORKERS' BATH TUe CROSS ST. ` ,�f( �
COMPENSATION INSURANCE SHOWER OWNER �����q� �
(This secfion need no4 be complet�d if the work involved by MAIL
the permit is for one hu�rdred dallars ($I�DO)or less.) LAVATORY ADDRES�I�� �
I certify that in ihe performance of ihe work for which this � �_,�,� ����.,
permif is issued, I shall not employ any person in any manner SINK CITY 4 �
so as to become subject to the Workers'Compensation laws. / ��1�
DISHWASHER CONTRACTOR� �
Date Applicant CLOTHES WASHER ADDRE55 �
�TICE TO APPLICANT: If, after making this Certificate of "� C� �'�
mption, you should become subjed to the Workers' SWIMMING POOL RECEPTOR
C,ompensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM � y CITY +�v�s-�}� — �
with comply wifh such provisions or this permit sha�l be l`' `� STATE uC,
deemed revoked. WATER HEATER LICENSE NO. � CLASS
UCENSED CONTRACTORS DECLARATION DISTRICT NO. PROCE�SED BY
GAS SYSTEM OUTLETS ��� \`
I hereby affirm that I am licensed under provisions of Chapter 9 " �z� C� �_��,�«F! ��
(commencing wifh Section 7000) of Division 3 of the Business OUTIETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALl��.TiON
License Number���� �.��Lic. Class� DATE
�/J� 1N�0� ��v���, �--".��-- F I NAL
ontracio �y Date �^��" �� BY
❑ I am exempt under Sec.
B.&P.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ �,��7 ��
Signature
TOTAL FEE � ��F
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
reby affirm ihaf I am exempt from the Contractor's License Address
�..w for the following reason (Section 7031.5, Business and ` '
Professions Code): City Tel. Na „ �
❑ I, as owner of the property, will do the work and the
structure is not intended or offered fo� sale (Sedion t` ' i
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm fhat there is a construdion 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 fhat I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulafing Plumbing, ond hereby
authorize representatives of this County Io enter upon the
above-mentio operty for inspection purposes.
SEE REVERSE FOR EXPIAN.�'fORY LAN�UACyE
� �.�o` �_����'-v`�
Signature of PermiStee Date