HomeMy WebLinkAbout1559A WORKERS'COMPENSATION DECLARATION qppI.ICATION FOR PLUMBiNC� PERMIT
I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/87 �":
76A667A '
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) `k i
certified copy thereof (Sec. 3800, lab. C.j }_;
Policy No. ,� r d� Company ����Fl(�d COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
� Certified copy is hereby furnished. � �� ���� �
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING -� r�G�����0�D�� ��
� Certified copy is filed with the county building inspection ADDRESS �/� �
depariment. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Q WATER CLOSET(TOILET) ����� ��� �
Date � � 9 Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' sATH TUe CROSS ST� �J� � � � "����j�
COMPENSATION INSURANCE SHOWER OWNER 7 �� � � , --��
(This section need not be corripleted if the work involved by MAI� y� v
fhe permit is for one hundred dollars ($100) or less.) LAVATORY ADDRESS �- ,r-jf��.e{,�< ��(�_ ,`�� � �
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CITY ����' � i ,� TEL. NO�
T� 1,��� zi�. �-�r�
as To bemme subject to the Workers'Compensation Laws. DISHWASHER �'
CONTRACTOR ' �� �u������
._.,.�
Date Applicant CLOTHES WASHER ADDRESS /�/
NnTICE TO APPLICANT: If, after making this Certifimte of Ex- J��� �n �,_/_ ,����
'ion,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
P Y p- CITY � C'S�y--cSI L7� TEL NO��.<�7�`�--�€'a
s .,n rovisions of the Labor Code, ou must forihwith com LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- r - STATE _.-- uC. ��y
ed. WATER HEATER LICENSE NO. �.������ CLASS �"`.0/
LICENSED CONTRACTORS DECLARATION �isTRICT No. PRO SSED sY
I hereby affirm fhat I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER � �� �'�;..��'�"��°"
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALI���18111
fect. "� � ,t/ DATE ����.���
License Numberc�/-�C.7 ��� Lic Class � ^�-/
� ��� ��) FINAL ''
Con}ractor�,�llc�/1������E�l��Date � LT BY
� �`_ .--`pl�rid'"'�lJ!�f�f_ 7���1 D � ��.
I am exem � er' ec.
�
B.&P.C. for ihis reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ �
� ��
Signature � TOTAL FEE �" E ��� �-�'-�,' i�e
SINGLE FAMILY � ��
HOME OWNER-BUILDER DECLARATION Plan check applicant ., .
I hereby affirm thaT I am exempt from the Contractor's License Name �
L�••- for the following reason (Section 7031.5, Business and � `' "' 3 �" '
ssions Code): Address
� I, as owner of the property, will do ihe work and ihe City Tel. No.
�� �;, � ✓
sTruciure is not intended or offered for sale(Section 7044, �
Business and Professions Code). �
CONSTRUCTION LENDING AGENCY
I hereby affirm ihat there is a construction lending agency for
the performance of ihe work for which this permii is issued
(Sec. 3097, Civ. C.).
Lender's Name
�
Lender's Address
I certify that I have read this application and state ihat the
above information is correct. I agree to comply with all County
or ' ces and State laws regulating Plumbing, and hereby
quthoriz represen ' of ihis County fo enter upon ihe
above- .entione propert, for inspeciion purposes.
��,�� �,� , �� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat re of Permittee / Date