HomeMy WebLinkAbout0925A WORKERS'COMPENSATION DECLARATION � �� P I '
� hereby vffirm ihat I have a certificate of consent io self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Ins�rance, 76A667A
or d certified copy th eof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEP-f. OF PUBLIC WQRKS
?S�Ss�-� s��� ��
Policy No. Company L ` �
� Cerfified copy is hereby fumished.
❑ FOR APPIICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRES '� S'� S/��e�� �
tion department. NUMBER FIXTURE OR ITEM � FEE LOCALITY
�r ��`-�, �
LJ, � WATER CLOSET
Date r APPIi4ant CROSS 8T. ✓�i�� ;� ��e �'3( ' �,�j�'�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
COMPENSATION INSURANCE SHOWER OWNER��7�� ���� ��P
(Thlm s�ctian need not b�cortople4od if tho work iwvolv�d by MAIL
4he permtf la For one hundr�d dolltars ($100)or I�sa.) LAVATORY ADDRESS 3t'�� /�
I certify that in the performance of Ihe work for which ihis
permit is issued, I shall not employ any person in any manner SINK CITY f �� �N � �,��_��0.
so as to become subjed to the Workers'Compensation Laws. DISHWASHER
CONTRA6T0 � ��,�, ���
Date ApplicaM CLOTHES4VASHER ADDRESS�� �0`'` ,/�,� v �f
"7TICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
:mption, you should become subject to the Workers'
...ompensafion provisions of ihe Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY p� �S� T ��3 _��3�
I
with comply with such provisions or this permit shall be =% `��STATE LIC. `-^�
deemed revoked. WATER HEATER LICENSE NO.��'��j'�� CLASS �<,c?
LICENSED CONTRACTORS DECIARATION DISTP,ICT NO. PzROCEs66�BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �/
,�� �1 � ��•__�C'��� .�_�_..
(commencing with Sedion 7000) of Division 3 of ihe Business OUTLETS OVER —
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ��L'��jf�[�
DATE
License Number���� Lic. Class���
�5,2,1�1q1/ LA���^�C ../'7'�'% FINAL
Contrador � Date,� BY
❑ I am exempt under Sec.
B.$P.C. for ihis reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ ��� ��;
Signature
TOTAL FEE �j,�
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
�reby affirm that I am exempt from the Confrador's License Address
.w for the following reason (Section 7031.5, 8usiness and
'�
Professions Code): City Tel, No. '
❑ I, as owner of the property, wiil do the work and the f � � '
siructure is not intended or offered fo� sale (Section
7044, Business and Professions Code). -
CONSTRUCTtON LENDING AGENCY �
I hereby affirm ihat there is a construction lending agency for
the performance of the work for which ihis permii is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read ihis application and state that ihe
above information is correct. I agree to camply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned property for inspecti purposes.
SEE REVERSE FOR EXPLA�l9�YO�Y �AFIGUAGE
��' �'/�J— ��
Sig ature of Permiitee Date