HomeMy WebLinkAbout1571A WORKERS'COMPENSATION DECLARATION � � I 'T
I hereby affirm that I have a certificate of consenf to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensatian Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COURITY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P�olfcy No.�Company ������'����%
Certified copy is hereby furnished. ����� ���� g��
❑ POR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING�� �
Certified copy is filed with the county building inspeo- ADDRESS �>� � • p�/�+/,n�'YJ� _/.�g���.
tion de ariment. NUMBER FIXTURE OR ITEM @ FEE =���v�l��,� F�'�}�-
P LOCALITY ` i ~� 7
Date_���ApplicaM WATERCLOSET NEAREST�---� <--� �
CERTIFICATE OF EXEMPTION FROM WORKERS' BAT.H TUB CROSS ST.�-L- /r�i''y)[>a;t� �F�. b�/-[�/?tt �F��7
COMPENSATION INSURANCE OWNER'—� � �-
SHOWER ti T /��- C�✓-�t!-o�d�/��..�.iJt�
(This seetion need not b�eomple4ed if 4he work involved by MAIL �
fhe permit is for one kundred dollars (�100)or I�sx.) LAVATORY ADDRESS �"�!�}/ ,�'/�!�/,%� �, �'7`'� .�
I certify that in the performance of the work for which this �
permii is issued, I shall not employ any person in any manner SINK CITY ��jc�� %�,��. TEL. NO, �-�, ����«�
so as to become subject to the Workers Compensqtion Laws, DISHWASHER `
CONTRACTOR �� �� ����������1 ����•
Date Applicant CLOTHESYVASHER ADDRESS �j ��
NOTICE TO APPLICANT: If, after making this Certificate of �C^�Jy J��✓ L��/�,'" ��L1�'-'
mption, you should become subjecf to the Workers' SWIMMING POOL RECEPTOR ,7
P P Y � LAWN SPRINKLER SYSTEM �� CITIy' C f� /Z. TEL. NO f,�
n ensation rovisions of the Labor Code, ou must forth- �{,�7���� _ ��.- �� �r-
with comply with such provisions or fhis permit shall be � STATE � LIC.
deemed revoked, WATER HEATER LICENSE NO. � ,l-��U�1� C�A55 � � •��
LICENSED CONTRACTORS DECLARATION DISTRICT NO, PRO SED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYS7EM oUTLETs .�j' ����
(commencing with 5ecfion 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in ful)force and effect. 5 PER SYSTEM FINAL ���,���jA��
DATE
� Lic, Class �" -�
License Numbe�?�'� �' �
--� FINAL
Contractor�'�/'�1e7/f,���.'S</i°�pate e f`� �' 8Y
� ��m��p���°�`-� �l� ��
B.$P.C, for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ p ��j
Signafure
TOTAL FEE �� �'�;,
Plan check applicaM
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name r
' �reby affirm that I am exempt from the Coniracior's License Address
for Ihe following reason (Section 7031.5, Business and � , , � ;
I-rofessions Code): City Tel. No.
❑ I, as owner of ihe property, will do ihe work and the `
struciure is not intended or offered fo� sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consiruction lending agency for
fhe performance of }he work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify fhat I have read this applicafion and state that the
above information is correct. I agree to comply with all Couniy
ordinances and Staie laws regulating Plumbing, and hereby
�_�a�1 orize repre'sentatives of fhis Counfy ro enfer upon fhe
� abov -mention operty for inspection purposes.
! SEE �EVERS� FOR EXPLAFI,4TORY LANGUAGE
����
, �� � � i
Sig ature of Perm' tee ate