HomeMy WebLinkAbout1564A WORKERS'COMPENSATION DECLARATION ' � L � I�
I hereby affirm ihat I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A
or a certified copy thereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P❑olicy No.<�,�1.�� 'r�c`�Company �!'�� �Lt,,a�� 'LJpj `o,' '�� �`�'� ��
�r
Certified copy is hereby fumished.
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING � ` � '
Certified copy is filed with the county building inspeo- ADDRESS -� �r�fit,ri��{'` � ��
lion deparfinenf. NUMBER FIXTURE OR ITEM @ FEE LOCALITY �7 � '9
� � � warER aoser �../i/f�Y)f��,Cy �a,-3,�.—
Dafe Applicant NEAREST ��. ,� �
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS Sl��_�%�/�'f`Y�0/C)G� ���. ��BZ�rf -.A�3iJ/
COMPENSATION INSURANCE SHOWER oWNER���-�,����� ,��_
(This section need not be comple4ed if 4he work involved by ��������� � " ��`1�"
}he permit is for one hundred dollars (;100)ar less.) LAVATORY MAII �j
ADDRES� � �//e.//�1� ��� 7f,rr , �
I certify that in the performance of the work for which this �
SINK CITY' 7EL. N
permit is issued, I shall not employ any person in any manner � � � ��i� . at��
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR -- � a 1�� �-� � �
,,{
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making lhis Certificate of � L��� � � 9�
SWIMMING POOL RECEPTOR -
�mpfion, you should become subjed to the Workers' ��q� TEL NO
,npensation provisions of ihe Labor Code, you must forth- � LAWN SPRINKLER SYSTEM ���`}S �'����� ��/f�"�����e��
wifh comply with such provisions or fhis permif shal) be STATE LIC,
deemed revoked, WATER HEATER LICENSE NO. -J��.� ���� CLASS �- --��
LICENSED CONTRACTORS DECLARATION DISTRICT No. P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Sedion 7000) of Division 3 of }he Business OUTIETS OVER � �� �'� ���- �
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �lAL9D�TEOR3
DATE
License Number �`�� ��� Lic. Class�''�`��
f / f ,(� FINAL
CoMractor%�����-`ia�/�y F���`�t�'`�ate � � `��"� BY
� 'f'.-.%a!J-�/-1�3r'���:t�°r��. /�����
I am exempt under Sec.
B.&P.C. for this reason
Plan cheek fee
Date:
PLUMBING PERMIT ISSUING FEE$ ��
Signature
TOTAL FEE (� �,�,
Plan check applicant
SINGLE FAMILY } , .,
HOME OWNER-BUILDER DECLARATION Name
'`�re6y affirm that I am exempt from the Contractor's License Address
for the following reason (Secfion 7031.5, Business and
,ofessions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Seciion
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there 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 fhat I have read this application and siate that the
above informafion is correcf. I agree to mmply with all Counfy
ordinances and State laws regulating Plumbing, ond hereby
authorize repre°sentatives of this County to enter upon the
�" abov -mentioned o erty for inspection purposes.
� �/ , �/- ��y SEE REVERSE FOR EXPLARIATORY LANt,�U�4GE
�� ,-Gi�p.� � �....�w�-Z.�C �-c..� c.`` , F � �O
Sig ature of Permitt�e Date