HomeMy WebLinkAbout0927A WORKERS' COMPENSATION DECLARATION ' � ' �'t°
f hereby affirm that I have a certifimte of consent to self 20-0026 DPW 6/87
insure, or a certificafe of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COUNl"Y OF LOS ANGELES DEPl'. OF PUBLIC WORKS
Policy No"]�.��Ompany��9��`�' L�C�''�
� Certified copy is hereby fumished. S � ��
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRE55 � � �� e
tio ep rtment. NUMBER FIXTURE OR ITEM @ FEE �OCALITY �
Date � Appli4ant WATER CLOSET NEARE57 e�n��� t
CERT FICATE OF EXEMPTION FROM W�RKERS' BA7H TUB CROSS ST��j�.�-j7��,! ��.Q�J3L��� ��;���
COMPENSATI�N INSURANCE SHOW[R OWNER ,��� ,,v
(This a�ctlon n�od nof b�campl�4ed if fh�work ir�valvmd by MAIL
tho permit le For one hundre�d dollars ($100)or lora.) lAVA7dRY ADDRESS �� % � /
I certify that in the performance of the work for which ihis
permif is issued, I shall nof employ any person fn any manner SINK CITYe.--�� � �f
so as to become subject to the Workers'Compensation Laws. DISH\NASHER
CONTRAGTOR o � � L �
Dafe Applicant CLO7HE5 WASHER AbDRESS
7TICE 70 APPLICANT: If, after making this Certificate of � P10� 1
impfion, you should become subject fo fhe Workers' SWIMMING POOL RECEp70R
�ompensafion provisions of the Labor Code, you must forth- �AWN SPRINKLER SYSTEM CITY � ,2�, T �l ��, ���
/
with comply with such provisions or ihis permit shall be 1�' � STATE LIC.
deemed revoked. WATER HEATER LICENSE NO.� � . CLASS ��
LICENSED CONTRACTORS DECLARATION DISTRICT No. PRO ESSEb BY
GAS SYSTEM OUTLETS � �
I hereby affirm ihat I am licensed under provisions of Chapter 9 � � � ��_��r�_�t
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER `
and Professions Code,and my license is in full force and effect, 5 PER SYSTEM FINAL ��L���TS��
License Number-��� �� Lic. Class �2� DATE
C -'i��l,'ll'9� �'�J'l/��— �^dC .��� / FINAL
on ractor ate � BY
❑ I am exempt under Sec.
B.&P.C. for this reason _
Plan check fee
Date:
PLUMBWG PERMIT ISSUING FEE$ � —���
Signature
TOTAL FEE � � �- ��
Plan check applicanf
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name r �
�reby affirm ihat I am exempt from ihe Coniractor's License Address
.�w for fhe following reason (Section 7031.5, Business and �; t:,
Professions Code): City Tel. No.
❑ j s � � '
I, as owner of fhe property, will do the work and the
siructure is not intended or offered for sale (Sectian
7044, Business and Professions Code). � `
CONSTRUCTION LENDING AGENCY
I hereby affirm that fhere is a construction lending agency for
fhe performance of ihe 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 Ihat the
above informaiion is correct. I agree to comply with aIl County
ordinances and State laws regulating Plumbing, and hereby
authorize represenfatives of fhis County to enfer upon the
above-meniione operfy fo ' specti n purposes.
SEE REVER3� FOR EXPLAf�JA�iORY LAPIGUAGE
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Signature of Permitfee Date