HomeMy WebLinkAbout1566A WORKERS'COMPENSATION DECLARATION �' � ' � '�
I hereby affirm ihat I have a certificate of conseni to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensafion (nsurance, 76A667A
or a certified copy thereof (Sec. 3800, Lab. C.) COUN7Y OF LOS ARIGELES DEPT. OF PUBLIC WORKS
P�olicy No.����`�/�Company �,�����f t)l'� ��� 'l� �f� �'�J
Certified copy is hereby furnished.
� POR APPLICANT TO FILL W(PRINT OR TYPE) BUILDING rry �
Certified copy is filed with ihe couMy building inspeo- ADDRESS �`7�� � � -`�f /'d')r . �( '��c.,
P NUMBER FIXTURE OR ITEM a fEE LOCALITY -_`� ��a��l�j
tion de artmern. � ���
Dafe ° �� Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS S[._�//�,ry?o�t? �!-?� �J L?d 7 �� C-y_ ��/�.D
COMPENSATION INSURANCE SHowER owNER`� �,`�y1-���� �,��������� ��e
(This secfion need no4 be compl�ted if the wark involved by MAII /�
4he permi4 is for one hundred �ollars ($100)or less.) LAVATORY AODRE55 ` /�l //��-G�'-�f� ���5 �� �
I certify that in ihe performance of ihe work for which this
permif is issued, I shall not employ any person in any manner SINK CITY �`,�-�� `��j��� TEL NO���� /����
so as fo become subjecf fo fhe Workers Compensation Laws. DISHWASHER / /
CONTRACTOR �
/'',�0�_�r�y 1-,>��✓-?SCi3/'E�--�,��l�'J �
Date Applicanf CLOTHES WASHER )
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS���/j ����p� �� lj_���
mption, you should become subject to ihe Workers' SWIMMING POOL RECEPTOR
,npensafion provisions ot the Labor Code, you must forth- l �� CI�fY - ���������� 7EL. N .-`.�,: ;,, ���
with comply with such provisions or this permit shall 6e ` LAWN SPRINKLER SYSTEM STATE LIC. �
deemed revoked, WATER HEATER LICENSE NO. ������l-v CLASS �`-h��
LICENSED CONTRACTORS DECL,4RATION DISTRICT No. PRO SED BY
I hereby affirm ihat I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS � y�
(commencing with Sedion 7000) of Division 3 of ihe Business OUTLETS OVER
Gd ��f.[-'%:s--d.���
and Professions Code,and my license is in tul)force and effect. 5 PER SYSTEM FINAL \/��0���6��
License Number=--��-� �'�G' Lic. Class � -°'L / DATE
p- FINAL
��/�/,�-�T�� �� Daie �BY
Contracfor c�
❑ ,I`ar�i��z�rr��t �underb`�'-c" ` d ��
B.&P.C, for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ ���
Signature
TOTAL FEE �-, ��,
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name , . ,
�reby affirm thpt I am exempt from the Contractor's License Address
for fhe following reason (Secfion 7031.5, Business and ,
Professions Code): City Tel. No.
❑ ( , :> � E`�
I, as owner of the property, will do the work and the
sfructure is not intended or offered for sale (Section
7044, Business and Professions Code). �
CONSTRUCTION LENDING AGENCY ��� °�.' �; � ��
I hereby nffirm that there is a construction lending agency for
fhe performance of the work for which this permii is issued
(Sec. 3097, Civ. C.),
Lender's Name
Lender's Address
I certify that I have read ihis application and state ihat ihe
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
h�r' e representatives of this County to enter upon the
above- entioned ope for inspection purposes. SEE REVERSE FOR EXPLANATORY LANC'vUAGE
.�'l._� ,:'�i_1 1�C '�.°-�✓ � f�iT
Signa ure of Permittee , ot�