HomeMy WebLinkAbout1565A WORKERS'COMPENSATION DECLARATION � TI L I IT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certitied copy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORI<S
Polic No�����'z�� Com an `���� ��`�
� yCertified copy is herebyP urnished. ��� �f� ���� `�
aFOR APPLICANT TO FILL W(PRWT OR TYPE) BUILDING � --, 7
Certified copy is filed with the county building inspeo- ADDRESS �c`� a_�, ��!/'YJ,y'7;� i� �L `�--d
tion department. NUMBER FIXTURE OR ITEM @ fEE LOCALITY '? �
� � ��� WATER CLOSET � ������ ���
Date Applicant NEAREST -�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS SL�,�s�i7�',.J� ��3.�� ��!J�� �y,��l,�JL�
COMPENSATION INSURANCE OWNER"--� ���.�,��
(This section need no4 be comple4ed if 4he work invalved by SHOWER �"7 e��j�;�1,����� �1/-� .-�ycJ c.
4he permif is for one hundred doflars (�100)or less.� LAVATORY MAIL
ADDRESS �`���j �/�C4��� . ��(,,,A,
I certify thal in fhe performance of ihe work for which this
permif is issued, I shall not employ any person in any manner SINK CITY��.^g��l1 ���� TEL N���,f��'.�,_f��
r�
so as to become subject to ihe Workers'Compensation Laws. DISHWASHER
CONTRACTOR���,C�JC€� ���C��f/��l.s ' ° / s/,
Date A licant CLOTHES WASHER
NOTICE TO APPLICANT:Pf, after making this Certifica9e of ADDRESS f� � / �� i �,�P ��c
�mpHon, you should become subject to ihe Workers' SWIMMING POOL RECEPTOR �--7-�
CITY �` r TEL. NO��,� ,
mpensq}ion provisions of fhe Labor Code, you must forih- ! LAWN SPRINKLER SYSTEM ' `� �-'� - � n�' ��1��A
with comply with such provisions or this permit shall be � STATE LIC.
deemed revoked, WATER HEATER LICENSE NO. �.����L CLASS �-�'-��
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM oUTLETs �j � y
(commencing with Sectlon 7000) of Division 3 of 1he Business OUTLETS OVER
���%f�,,___�_,
and Professions Code,and my license is in full force and effect, 5 PER SYSTEM FINAL ���0���'0��
DATE
License Numberm`-�'�-�-��'��' Lic. Class �`---2 7
FINAL
Contractor��J�-�����c��Date � I7 c�� BY
❑ °y��d�-� �77�� �"' .l� �
I am exempt under S�c��` 4 �`'� �
8.&P.C, for ihis reason Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ �°� �'�
Signature
TOTAL FEE �, ���
Plan check applicanf „ ,
SINGLE FAMILY "
HOME OWNER-BUILDER DECLARATION Name
'' =reby affirm that I am exempt from the Conirador's License � E ` �� '
� for fhe following reason (Secfion 7031.5, Business and Address
rrofessions Code): City Tel. Na �
❑ I, as owner of the property, will do ihe work and the ' `'
strucWre is not intended or offered for sale (Secfion
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm}ha1 there is a construction lending agency for
fhe performance of fhe work for which ihis permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that ihe
above information is correct. I agree lo comply with all Counfy
ordinances and State laws regulating Plumbing, and hereby
authorize repre`senfatives of ihis County to enier upon fhe
a ov menfione erty for inspection purposes.
SEE �EVERS� FOR EXPLAfJiATO�Y �.ANGUAGE
;� �{���� ��',��,�
Sig ature of Permittg'e Date