HomeMy WebLinkAbout1572A WORKERS' COMPENSATION DECLARATION " � � I �
I hereby affirm ihat I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a cerfifimte of Workers' Compensation Insurance, 76A667A
or a certified copy ihereof (Sec. 3800, �ab. C.) COUIVI'Y OF LOS ANGELES DEPT. OF PUBLIC WORKS
Polic No. � � '7`� Com an ��rjl�--��'J-�
� YCeriitied copy is herebyf urnished. �� �/ ���
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS �,°� 7 ✓ -�_ 1�,�,
fion d partment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY � ,
� I' � WATER CLOSET ��������� ����
Dafe Applicanf NEAREST<-
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST,����117fi�D� c�,f7� ��.1���f--�a���✓�
COMPENSATION INSURANCE OWN��"�������Ca�j ��Y��,�,���J�� _�_y��,
SHOWER
(This seefion need not be cnenpl�4ed if 4he work involv�d by MAI� //� /� /1� �
fhe permit is for one hundeed dollars ($100)oe less.) LAVATORY ADDRESS�.���� �!s�(X.�/;�� ,+�—;� �
I certify that in the performance of the work for which this d -
P p Y y P Y SINK GTY��rj •� r �,�_ TEL. NO �t,f,�� /��
ermif is issued, I shall nof em lo an erson in an manner � ��.�`
so as fo become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR ����,�r�� ��� .`���� .
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRE55 �� ��+� ��'���� ���
mption, you should become subjecf to ihe Workers' SWIMMING POOL RECEPTOR C17Y��---� TEL. NO.
npensafion provisions of 1he Labor Code, you musi forth- � LAWN SPRINKLER SYSTEM � �� '?''t��� /�f�%37�6�`
with comply wifh such provisions or fhis permit shall be STATE , LIC.
deemed revoked. WATER HEATER LICENSE NO..�.�,��,.,�� CLASS ��-�����
UCENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY
I hereby affirm fhat I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS � �,
�� �� 1 } - ,�-�%
(commencing wifh Section 7000) of Division 3 of the Business OUTIETSOVER -
and Professions Code,and my license is in full force and effect, 5 PER SYSTEM FINAL �e��,I�d4Ti�Q�
License Number --���' �'��d Lic. Class � �' DATE
J�,E� FINAL
Coniracfor�'���L`��/ '"��'�Dafe�/ � BY
❑ I m ex�pt Gnde�S�eE. 'z'�� ` ���.��
B.EP.C. for ihis reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ Jr� �,, `
Signature
TOTAL FEE ; ��y
Plan check applicant
SINGLE FAIv11LY
HOME OWNER-BUIIDER DECLARATION Name
i '
' ' �reby affirm thaf I am exempt from the Contractor's License Address
for the following reason (Section 7031.5, Business and
r�ofessions Code): City Tel. No.
❑ I, as owner of the properfy, will do ihe work and fhe
strucfure is not intended or offered fo� sale (Secfion
7044, Business and Professions Code),
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consfruction 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 Ihis applicalion and state that ihe
above information is correct. I agree to comply with all County
ordinances and Siate laws regulating Plumbing, and hereby
orize repre°sentatives of this County to enter upon Ihe
abo e-menfion erty for inspection purpose .
�� �r� SEE REVERSE FOR EXPLAfd�4TORY LANCUAGE
�_. .l.F�..4��� � /��-1!f �-�� �� J�
Si nature of Permitt e Date