The URL can be used to link to this page

Home My WebLink About0926A WORKERS'COMPENSATION DECLARATION I I I I � hereby affirm that I have a certificate of consenf to self 20-0026 DPW 6/87 insure, or a cerfifimfe of Workers' Compensafion Insurance, 76A667A or a certified copy thereof (Sec. 3800, �ab. C.) COUl�ITY OF LOS ANGELES DEPT. OF PUBLIC WORI<S ` 7�'�'S��--�� P❑o icy No. Company ^ 3� Certified copy is hereby furnished. aG � fOR APPLICANT TO FILL W(PRINT OR TYPE) BUILDING � � Ceriified copy is filed with the county building inspec- ADDRESS tioP ep rfine,�nt. NUMBER FlXTUREORITEM @ FEE LOCALITY � �� WATER CLOSET �� Date � . Applicant NEAREST , CERTIFICATE OF EXEMPTION FROM WORKERS' BA7H TU6 CRoss 5L,�� i „n,(.�J ,,[�«,9 , �}/� COMPENSATION INSURANCE OWNER �� •�. SHOWER (This section need no6 be completed if 4he work involved by MAIL / g� the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS��/ /�Q('l/�f 1 certify fhat in fhe performance of ihe work for which ihis permif is issued, I shall not employ any person in any manner SINK CITY� _�„ "._/ ��,� �N^�.5� !��' c.;.+/ so as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTOR y�� , �.;g , �r', GI�M Dafe Applicant CLOTHES WASHER ADDRESS ' ` 7TICE TO APPLICANT: If, afier making this Certificate of J1�� ;mpfion, you should become subjeci fo ihe Workers' SWIMMING POOL RECEPTOR �ompensation provisions of ihe Labor Code, you must forth- � LAWNSPRINKLERSYSTEM � CITY • � � iq� l� _ , _�� J with comply with such provisions ar this permit shall be �' STATE uC. ^� deemed revoked. WATER HEATER LICENSE N0.3�� CLASS ��/ LICENSED CONTRACTORS DECLARATION DISTRICr NO. PROCES¢ED BY I hereby affirm that I am licensed under provisions of Chopter 9 GAS SYSTEM OUTLETS � �� c�J`��4� ��'�� `i„asl_y�- _ (commencing wifh Section 7000) of Division 3 of fhe Business OUTLETS OVER � � and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ��ll��'r6�� License Number i�� Lic. Class �',�7 DATE ,p `� FINAL �fi��el'Cl�� 9��-'"Dat��J�^�^r�� BY C ntr ctor ❑ I am exempt under Sec. B.&P.C. for ihis reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ ��j ��y Signature TOTAL FEE � . �_, Plan check applicant , SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name reby affirm fhat I am exempt from fhe Contractor's License Address ' � __ov for the following reason (Section 7031.5, Business and ' Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and ihe strucfure i� nof infended ur offered fo� sale (Section � � �- � 7044, Business and Professions Code). CONSTRUCTION IENDING 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.). 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 camply with all County ordinances and State laws regulating Plumbing, and hereby authorize repre`sentaiives of this County to enter upon the above-mentioned property fo i " ion purposes. SEE REVERSE FOR EXPLe4Fdi4TORY LAP1CaUPeGE �"/�� Signalure of Per ittee Dafe