HomeMy WebLinkAbout1570A WORKERS' COMPENSATION DECLARATION L' TI � L I IT
I hereby affirm fhat I have a certifimfe of consent fo self 20-0026 DPW 6/87
insure, or a cerfificafe of Workers' Compensation Insurance, 76A667A
or a certitied copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORI<S
P❑olicy No.�`? P'�'_ '� Companye���c� �f,-t'n�.� ./- i
Certified copy is hereby fumished. �`��� � �� /
FOR APPLICANT TO FILI IN(PRINT OR TYPE) BUILDING ��
� Certified copy is filed with fhe county building inspeo ADDRESS ��3 �`% �j;�C'yJ /` �'� �, d��
tiondeparfineni. NUMBER FIXTUREORITEM @ FEE �aCALITY.�7" �'_��,a-
�� WATER CLOSET /�,���� � �
Date � � Applicanf NEAREST �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUs CRoss ST.�%/,�o'r1O�Y.� ��e�' ,��%f � ��<l�
COMPENSATION INSURANCE SHOWER �WN�_� � ������ � l � G'
(This section need not be comple4ed if 4he work involved by MAIL .� � y
4he permif is 6or one huodred dollars (;100)or less.) LAVA70RY ADDRESS@-�.J�c? / � �� �-)-�/ ���/'�
I certify that in the performance of ihe work for which Ihis
ermit is issued, I shall not em lo an erson in an monner SINK CITY /'� ,.- TEL. NO r1
P P Y Y P Y I,�Q;>/ Y�?��� t� 4°��c:r�/
so as fo become subject fo the Workers'Compensation Laws. DISHWASHER �
CONTRACTOR� ��� /,���` � �
�✓
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, afler making this Certificate of SWIMMING POOL RECEPTOR 0 �� J � �
mption, you should become subject to the Workers' CITY�`��
,npensalion provisions of fhe Labor Code, you must forfh- � LAWN SPRINKLER SYSTEM ')j�}£�z t7c� TEL NO ,J�� 1el
with comply with such provisions or fhis permit shall be STATE LIC. ,,
deemedrevoked. WATERHEATER LICENSENO. � /y-�� CLASS �'��
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO. SSED BY
I hereby affirm that I am licensed under provisions of Chapler 9 GAS SYSTEM OUTLETS .� �,�
—�'� 1�'`��.�
(commencing with Section 7�0) of Diuision 3 of ihe Business OUTLETS OVER
and Professions Code,and my license is in full force and effeci. 5 PER SYSTEM FINAL
VEaLID�.TIOR,1
License Numbe�--��-�n . +��n Lic. Class��_�-/ DATE
� �� �y FINAL
Contracfor ' '-����4��y"'''��'�Date__� j✓ �`�� BY
❑ I art�"ekeFnpt`GrSder SC��„f�:J�,
B.&P.C. for ihis reason
Plan chetk fee
Date:
PLUMBING PERMIT ISSUING FEE$ �y ��,
Signature
TOTALfEE �� �
Plan check applicant
SINGLE FAMILY , �� � ,_.
HOME OWNER-BUILDER DECLARATION Name
�reby affirm fhat 1 am exempt from the Contracfor's License Address � � � " ''
for the following reason (Section 7031.5, Business and
Professions Code): City Tel. Na
❑ I, as owner of the property, will do the work and the
sfructure is not intended or offered fo� sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that fhere 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 ihat I have read this application and state that fhe
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
ze repre°sentatives of ihis County to enter upon the
� above- enfion erfy for inspection purposes.
SEE REVERSE FOR EXPL,41Va4TORY LANGUAGE
� .''� ��� . `'� y' � � � �''� �
Sign ture of Permiite Date