HomeMy WebLinkAbout1567A WORKERS'COMPENSATION DECLARATION �� � ' '
I hereby affirm ihat I have a cerfificafe of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensafion Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS -
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P�olicy No�����"��� Company��1� �t r�1'�
Certified copy is hereby furnished. ��� � ��
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING e,
Certified copy is filed with the county building inspeo- ADDRE55 ,I�� ,��, `lj� '%,j J��p' G, �
tion deparfinent. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY ���,/��rn�� �
Dafe L� r ���,_Applicant WATERCLOSET NEAREST,—. � �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB cRoss s�,±��f,�yr� i� ,�}-.�- �/_Up�-�/�,��/��
COMPENSATION INSURANCE SHOWER OWNER �����.,y� , ���� �"�/���,���
(Thle oection need not be compl�4ed i$the work involved by
the permit is far one hundred dollars ($100)or(es�.) LAVATORY MAIL �--. e„ �
ADDRESS ��� l ��� � l� �j
I certify that fn ihe performance of the work for which this
permit Is issued, I shall not employ any person in any manner SINK CITY ��}��� ����-��y TEL. N .-7r.,$ Q�, �u�,
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so as fo become subject to the Workers'Compansafion Laws. DISHWASHER
CONTRACTOR --d���J ,(S���}��� �� �
t�`
Date Appllcant CLOTHES WASHER
NOTICE TO APPLICANT; If, after making this Certificate of ADDRESS �✓���/ ,l/y�y��������� f-�(Jy�
mpfion, you should become subject fo the Workers' SWIMMING POOL RECEPTOR �--�
CITY� �'���r-� TEL. NO ✓.
mpensatlon provisions of fhe Labor Code, you must forih- / (��- 7��f ���f.�f/�p
with comply with such provislons or ihis permit shall be �AWN SPRINKLER SYSTEM � STATE
deemed revoked, WATER HEATER LICENSE NO. ,�� � LIC �•-,��
'�C=L✓ 'j�-� CLASS �
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby afflrm that I am licensed under provisions oF Chapter 9 GAS SYSTEM oUTLETs �,,
��� `�'� ,��--s��=-��,�
(commencing with Section 7000) of Division 3 of fhe Business OUTLETSOVER �
and Professions Code,and my license is in full force and effect, 5 PER SYSTEM FINAL va�e���oor�
License Number-������� �� Lic, Class C�"-�� DATE
/`��1,�-9.e�9���l��f�6'� � �� � FINAL
Confractor Date c BY
❑ I am' xe e p�n�der���c./ "'C°"'� , � :�:�,'�1
.
B.$P.C. for ihis reason
Plan check fee
DaPe:
PLUMBING PERMIT ISSUING FEE$ ,�� . �
Signature
TOTAL FE� �, �
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
�reby affirm that I am exempt from the Contractor's License Address
i for the following reason (Section 7031.5, Business and "
Professions Code): City Tel. Na. � , 4
❑ I, as owner of fhe property, will do the work and the
structure is not intended or offered fo� sale (Section = �
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that 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 fhat I have read Ihis application and state Ihat the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
qze repre'sentatives of this County lo eMer upon the
above- entiore rop y for inspedion purposes.
� � � / �) SEE REVERS� �OR EXPL�.NATORY LAPdGIJAGE
1 '�,.a. `. ..G�'�KY,f £, U� / / D ��
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Sign ture of Permiite� Date "