HomeMy WebLinkAbout1563A WORKERS'COMPENSATION DECLARATION � � I '�
I hereby affirm ihat I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a cerfificate of Workers' Compensation (nsurance, 76A667A
or a certified copy thereof (Sec. 3800, I.ab. C.) COUIVTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P❑olicy No.7��,�b -r�',�Company���T� �'ct��7/� .E�_+-� ��✓°-� �.�1 �` ��.�—
Certified copy is hereby furnished. �5
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING � ` � ���
Certified copy is filed with the county building inspec- ADDRESS f„� c.. , �G�fy,�t°y)!`dl�-Gt -c
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY P-1) ^t3
Da1e � d Applicanf WATER CLOSET NEAREST. /������� �`�
CERTIfICATE OF EXEMPTION fROM WORKERS' BATH TUB CROSS ST��j.Gj�'1'�f_),U,(� ,_ ,, �/`.l�L���� `-���)�i�J
COMPENSATION INSURANCE SHOWER OWNE ;� ��.�- _� ���� �����j�������� ���
(This secfion need no4 be comp184�d if th�work involved by MAIL ,+�
}he permit is for one hundred dollars ($100)ar I�ss.) LAVATORY ADDRES�� p"r �,�1�-� � ��� j„r', A�
I cerfify fhat in fhe performance of fhe work for which this
permit is issued, I shall not employ any person in any manner SINK CITY�1'��� ����� TEL N .-�����'j ,���
so as to become subjecf to the Workers'Compensafion Laws, DISHWASHER "' '
CONTRACTOR�� � � �,���y-�r ���/ ��
Date Appf icant CLOTHES�NASHER '
NOTICE TO APPLICANT: If, after making this Certificate of � ADDRESS ���� ' ����iy��� .�-�r
�mptlon, you should become subject to ihe Workers' SWIMMING POOL RECEPTOR
mpensation provisions of the Labor Code, you musf forth- / � � CIT���������� TEL. NO.`�, f.
LAWN SPRINKLER SYSTEM f ���'��`"
with comply wifh such provisions or this permit shall be r STATE
deemed revoked, WATER HEATER LICENSE NO.�7 �� ��cs� C ASS � ��
LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY
GAS SYSTEM OUTLETS �
I hereby affirm that I am Iicensed under provisions of Chapter 9 �� .�-
(commencing with Secfion 7000) of Division 3 of the Business oUTIETSOVER '`�"` )��`'��`� ��"'�
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATBO�
`��'�Lrz ls .� ��. ��2�,7 DATE
License Number �� Lic. Class
�/�LJ���f�J��`� te� C'� BY AL
Contractor fa
❑ I am ze�n�ec Jr•'�"=�� �F r�v�
B.�P.C. for fhis reason
Plan check fee
DaVe: pLUMBING PERMIT ISSUING FEE$ °m'
Signature
TOTAL FEE �
Plan check applicant ' '
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
' ' �reby affirm that I am exempt from the Contractor's License Address
for fhe following reason (Section 7031.5, Business and � ( , ��
r�ofessions Code): City Tel. No.
❑ I, as owner of ihe property, will do fhe work and the '
strucfure is not intended or offered fo� sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDWG AGENCY
I hereby affirm that there is a construction lending agency for
ihe performance of the work for which fhis permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify Ihai I have read this application and state that fhe
above information is correct. I agree to comply with all Counfy
ces and State laws regulating Plumbing, and hereby
�uthorize epre°sentatives of Ihis County to enter pon the
above-me ioned roperfy for inspecfion purposes.�
6- _ � , ��� �� �L�,�' �� SEE REVERS� FOR E3fPLAi�lATO1�Y LANCylJAGE
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Signat e of Permitiee � �ate '