HomeMy WebLinkAbout0924A WORKERS'COMPENSATION DECLARATION ' TI F L I � IT
` hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a cerfificate of Workers' Compensation Insurance, 76A667A
or a certifi copy th reof (Sec. 3800, lab. C.) COUIVl'Y OF LOS AIVGELES DEPT. OF PUBLIC WORI<S '
?S������'� 5�.4�j- /���t�'C'�
Policy No. Company;T �� � L '
� Certified copy is hereby furnished. BUILDING .
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) o
Certified copy is filed with the county building inspeo- ADDRE55 �� S �'i,,�'1/ �,�/� r
tion de ari enf. NUMBER fIXTURE OR ITEM @ FEE
LOCALITY � ��
WATER CLOSET
Date � Applicant CROSS ST.�j9 �i� � /�(, (� ��(�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB `
COMPENSATION INSURANCE OWNER
(This sec4ion need not be camplePed if the work involved by SHOWER �,
the permi4 is for one hundred dollors ($100)or less.) LAVATORY MAII
ADDRESS�' u JcJ��1�1/
I certify that in 1he performance of fhe work for which Ihis
permit is issued, I shall not employ any person in any manner SINK CITY � � � O. �,5�
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR���`�,� � �,e �-�
/ S�
Dafe Applicant CLOTHES WASHER ADDRESS � ���✓ � � '1
'�TICE TO APPLICANT: If, atter making this Certificate of
°mpfion, you should become subject to ihe Workers' SWIMMING POOL RECEPTOR
�ompensation provisions of the Labor Code, you must forth- � CITY ��v� � E} O
LAWN SPRINKLER SYSTEM "`
with comply with such provisions or this permit shall be ' � STATE LIC.
deemed revoked, WATER HEATER LICENSE NO. 3� �� CLASS `�
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCES�E BY
I hereby affirm that I am(icensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �: Eg;�d"� C� ����,., �/
(commencing with Secfion 7000) of Division 3 of fhe Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �A�.I��T0�9�
License Number�����_Lic. Class �'Z+/ DATE
����t/4'/��4'�-S'�9PF, �^�C.,. �q FINAL
Confracfor Date -��'��'� / BY
❑ I am exempt under Sec.
B.RP.C. for th�s rea5or, Plan check fee
Date; p�UMBING PERMIT ISSUING FEE$ �� �
5ignature ��
TOTAL FEE �� ��
Plan check applimnt
SINGLE FAMILY ,
NOME OWNER-BUILDER DECLARATION Name
�reby affirm that I am exempt from the Contractor's License Address
..w for fhe following reason (Section 7031.5, Business and
Professions Code); City Tel, No.
❑ I, as owner of the properiy, will do the work and ihe
strucfure is not intended or offered fo� sale (Section
7044, Business and Professions Code).
t` ,s �; '4 <'i `�{�
CONSTRUCTION LENDING AGENCY
I hereby affirm that ihere is a construction lending agency for
the performance of fhe work for which this permit is issued '° '
(Sec, 3097, Civ. C,). ; ��
Lender's Name
Lender's Address
I certify ihai I have read fhis applica�ion and stafe ihat the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
auihorize representatives of fhis Counfy to enter upon fhe
above-mentioned properfy for ins'e ' n purposes.
SEE REVERSE FOR EXPLANATORY Li4NGUAGE
�y' �"�/�"�'�'
Signature of Permittee Daie