HomeMy WebLinkAbout1561A WORKERS' COMPENSATION DECLARATION APPLICATION F R PLl1Ni61N� PERMIT i
I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/87 ^�'°F
76A667A � p
sure,or a certificate of Workers'Compensation Insurance,or a CE 8V(REV. 8/86) � �
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. � h ° Company �� ��5� COUNTY QF LOS ANGELES DEPT. OF PUBLIC WORKS F�
� Ceriified copy is hereby furnished. ��� ,�r ��� ��
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �
� Ceriified copy is filed with ihe counfy building inspection ADDRESS ��C'J 0,.,'7. �Gt�3'7p7'�l� ���-�.
depariment, NUMBER FIXTURE OR ITEM �a FEE
r A WATER CLOSET(TOILET) LOCALITY ������o�� ���_
Date Appl icant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.�/�lf'J'/,�J�L� � `���)� -��/1
COMPENSATION INSURANCE SHOWER �WN��`77 j�/�_,�'f.�- C����,//zg f?�L�(r�J- P�
(This secfion need not be completed if the work involved by MAIL
the permit is for one hundred dollars (5100)or less.) LAVATORY ADDRESS �-1���1 `-J-�� � �s
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SWK CITY���1�/= i �' TEL N .��� O ��
—t�-� C� a
as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR����� /�����A��-�a����/ ��
Date. Applicani CLOTHES WASHER 7
ADDRESS '�
NnTICE TO APPLICANT: If, after making this Certificale of Ex- ����/ �7� jC.�/�lf� /�j?��
`ion,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
a. �n provisions of the Labor Code, you must forthwith comp- / CITY - ���rl'j?�p� TEL. N ��� ,- y C�
LAWN SPRINKLER SYSTEM �—�L-
ly with such provisions or this permit shall be deemed revok- F 4 STATE ,� uC.
ed. WATER HEATER LICENSE NO. 'S�� �{� CLASS �-,.Ci
LICENSED CONTRACTORS DECLARATION DISTRiCT No. PROCE ED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of fhe Business OUTLETS OVER `� .� !��= }�"�`
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATIOFI �
fect
� DATE �
License Numbei"`�- '�`ss'��`��� Lic. Class �'� �
Contractor//�I���/��/—/�-JR-�!�'�,@'�.�1e � 1� a� gIY AL
��
�j����� ��
� I m ex�emp�vY,r'�de7 Sec.�"� `��� �7 '�
�.�
B.$P.C. for this reason �
Plan check fee �
�
Date: PLUMBING PERMIT ISSUING FEE$
Signature � � �� �� '� �i �� - . ,.
TOTAL FEE �
SINGLE FAMILY Plan check a licant '
HOME OWNER-BUILDER DECLARATION PP�
I hereby affirm that I am exempf from fhe Contrador's License Name f �� ��� j ���.`'i i�
l� � for the following reason (Sectian 7031.5, Business and
�ssions Code): Address , ,
� I, as owner of the property, wi�l do the work and ihe City Tel. No. � r;� �
structure is not intended or offered for sale(Section 7044, �
Business and Professions Code). �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construcfion Iending 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 ihat I have read this application and state that ihe
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
ize representpiives of this County to enter upon ihe
;' above mentione ty for inspection purposes.
� � ��� " � �� � SEE REVERSE FOR EXPLANATORY LANGU.4GE
Sig ature of Permitte�' Date