HomeMy WebLinkAbout1562A WORKERS'COMPENSATION DECLARATION �� ' � ; f �
I hereby affirm that I have a certificate of consenf to self 20-0026 DPW 6/87
insure, or a cerfificate of Workers' Compensafion Insurance, 76A667A
or a certified copy fhereof (Sec. 3800, �ab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORI<S
Polic No.-r� �"7fl',�`p�Com an �T�� �tt�1-� `� `
� YCeriified copy is herebyf urnished. ����7� ��� ��
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING .j y ,� �
� Certified copy is filed with ihe county building inspeo- ADORE55 d _ ��, ��/��Y;a�t���L�� �
tion depariment. NUMBER FIXTURE OR ITEM a FFE
Dafe ������' WATER CLOSET LOCALITY ��/��.y�,��� ��',,�s:
�y.
� Applicani NEAREST� /
CERTIFICATE OF EXEMPTION FROM WORKERS' BA7H TUB CRoss S1'`'�/��'J"JDi(J�L'�� �l_L��'� �/��/�`�
COMPENSATION INSURANCE OWNER���/7
(This section need not be comple4�d if fhe work involved by SHOWER c-,`����c;j'/��f� ��,1�'d'h"s�l� ._-fy..9c_
4he permit is for one hundred dollars ($100)or less.) LAVATORY MAII � d � ,�
ADDRESS��a1/ / ��s�- , �L c., �
I certify ihat in the performance of the work for which this �
permif is issued, I shal) not employ any person in any manner SINK CITY, .f= _ ,,- TEL. N �d�
�-��� � -
so as to become subjecf to fhe Workers'Compensation Laws. DISHWASHER '
CONTRACTOR������ �/���-y-x��,,.¢ ���. - �9
_A
Date Applicant CLOTHES WASHER ADDRESS `'J J
NOTICE TO APPLICANT: If, after making ihis Certificate of 1 �� �y��^ -��-�//� /Y���''_,>
�nplion, you should become subject to fhe Workers' SWIMMING POOL RECEPTOR
npensation provisions of ihe Labor Code, you musf forth- CI�Y� �'� `��,� TEL NO ��,�/i������
/ LAWN SPRINKLER SYSTEM �
with comply wifh such provisions or lhis permit shall be STATE � LIC. �� e
deemed revoked. WATER HEATER LICENSE NO. ��(��-.�/..o CLASS �
LICENSED CONTRACTORS DECLARATION DISTRICT No. PROCESSED BY
�hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ���
�-// / 1 �j.-" . ,9e.; , — l
(commencing with Section 7000) of Division 3 of ihe Business OUTIETS OVER � �� "'�
and Professions Code, and my license is in full force and effed. 5 PER SYSTEM FINAL ��L����6��
°�� � � DATE
License Number `��-- ��`�� Lic. Class C,'
�/ �y � J FINAL
CoMracfor����✓��l f °'����Pl'ate BY
❑ am""��mpt�under Sec!`�C_ . ���i���'�
B.RP.C. for fhis reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ � e��
Signature
TOTAL FEE �� �;�
Plan check applicant "
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ' ` -
�reby affirm that I am exempt from the Confractor's License Address ! ` �1
for fhe following reason (Section 7031.5, Business and
I'rofessions Code): City Tel. No.
❑ I, os owner of fhe property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consiruction lending agency for
fhe performance of the work for which this 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 to comply wiih all CouMy
ordinances and State laws regulating Plumbing, and hereby
r�'ze repre`sentatives of fhis County to enter upon ihe
/ above entio erty for inspecfion purposes.
/ •� ��/ �?,�J SEE REVERSE FOR EXPLAPl�4TORY LAN(sUAGE
I��i � � �o��-r=y (l ��7 Q !�
Sig ature of Permif�e Date