HomeMy WebLinkAbout1568A WORKERS' COMPENSATION DECLARATION I TI L I i�! � IT
I hereby affirm that I have a cerfificate of consenl to self 20-0026 DPW 6/87
insure, or a cer�ificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof(Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P❑olity No��.���"Q�Company�-'��� ���� ,� ��9
Certified copy is hereby furnished. , F �
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ��� ��
� Certified copy is filed with the county building inspeo- ADDRESS i' � , e�l�/?)y?7�/`,�I �¢��-
fiondeparimenL NUMBER FIXTUREORITEM @ FEE LOCAUTY �
��.�1�7'7f��..9.� �
WATER CLOSET
Dafe � �� Applicant CROSSSST�/,�1���9L�L��✓�l�' c.��/..1,��`"'-`-���-�
CERTIFICATE OF EXEMPTION FROM WORKERS' BAT.H TUB
COMPENSATION INSURANCC SHOWER oWNER�-'' �7 ��� ��f��,���.� ��
(This section need no4 b�compl�4ed if 4he work involved f�y MAIL
4he permit is For one hundred dollars(�100)or less.) LAVATORY ADDRESS�� 'pj✓ /��_[,1�� �(��_ �` (� /.,}�
I certify that in the performance of ihe work for which this ,
permit is issued, 1 shall not employ any person in any manner SINK CITY ���.�-� 4��� TEL NO.✓r1�1 p�� ��`
so as to become subject fo the Workers Compensation Laws. �9
DISHWASHER CONTRACTOR �
��ii�Ji�y /,��������- --�-� .�i,
Date Appiicanf CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS ���� �?��'d,�)�j���'� ���
mpfion, you should become subjecf to ihe Workers' SWIMMING POOL RECEPTOR �
CI {?� TEL N
npensation provisions of the Labor Code, you must forfh- ) LAWN SPRINKLER SYSTEM � �-��, � ���"J���� � �����������'=�`z''
wifh comply wiih such provisions or this permit shall be / STATE -� _ �� uC.
deemed revoked, WATER HEATER LICENSE NO. <��r�.� �w--.��-� CLASS �-� "��--�
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRO ESSED BY
I hereby affirm ihaf I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Secfion 7000) of Division 3 of fhe Business OUTLETSOVER � ����r�fF
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �4ALOD�$TO��
License Number�`�'C'�`�� Lic. Class�.-���� DATE
� Q FINAL
CoMractor ��"���������Bafe 1���U BY
❑ I arTi ezempf'ur�de�r S�:'�G; `��e��'f�/�
B.$P.C, for this reason
Plan chetk fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature �� ��
TOTAL FEE �� �'� �� ,
';
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
' ' �reby affirm that I am exempt from the Confractor's License � ' �' �
for fhe following reason (Section 7031.5, Business and Address
rrofessions Code): City Tel. Na
❑ I, as owner of fhe property, will do the work and fhe c . ,
structure is not intended or offered for sale (Sedion
7044, 8usiness and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby nffirm thaf there 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 that I have read this application and state that the
above information is correct. I agree to comply with all Counfy
ordinances and 5tate laws regulafing Plumbing, and hereby
auihorize repre°sentatives of ihis County fo enfer upon fhe
a ov -menfione rfy for inspection purposes.
SEE REVERSE FOR EXPLAfdRaTORY LAIVC9UAC3E
. L�� � c�i L�r�zu= � � 7 �'�
Signature of Permitte Date