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Home My WebLink About1557A WORKERS'COMPENSATION DECLARATION /� ppl��'�p, � � ��'�� 20-0026 DPW 4/87 /�1 r r 1�1 ` I hereby, affirm that I have a certificate of consent fo self in- 76A667A � sure,or a cerfificate of Workers'Compensation Insurance,or a CE 817(REV. 8/66) 1 t certified copy ihereof (Sec. 3800, Lab. C.) Policy No.� ' '- r5'Company �%�T��=t�.J� COUNTY OF LOS ANGELES DEPT. OF PU_BLIC WOf2KS � Certified copy is hereby furnished. �`�� 6`"��'� � FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING � Certified copy is filed with the county building inspection ADDRESS '� �� ,y�,t�/j� ��7�' department. NUMBER RXTURE OR ITEM Ca FEE �� LOCALITY ��i� �� J �� WATER CLOSET(TOILET) Date Applicant NEAREST, CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST�-.�l✓�J'"Y)YI�,1,�� =J-,� -��J�/) �l�f�t�-iLEf} COMPENSATION INSURANCE SHOWER �WN� ` �''�f;Y,1�/' ��!� �,��l ' ,�� '� (This seciion need not be completed iF fhe work involved by MAII the permit is for one hundred dollars ($100) or less,) LAVATORY ADDRESS�/�'�/ -�/�(�f;l� �;#�,� ' � , �,� I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY �'��-� �v�� TEL. No��j�,�� as to become subject to the Workers' Compensation Laws. DISHWASHER CONTRACTOR�� /�.�fv�� i�� Date Applicant CLOTHES WASHER NnTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR ADDRESS /��r� ��I �- �yq��/�i ,�}�%6. tion, you should become subject to the Workers'Compen- ..J ,r9 a. on provisions of the Lpbor Code, you must forthwith comp- 1 LAWN SPRINKLER SYSTEM � �� h��.�P��%�f��—�' TEL. N .l✓� � �1 ly with such provisions or this permit shall be deemed revok- t STATE ,� , uC. ed. WATER HEATER LICENSE NO. �� CLASS �'--�-t7 LICENSED CONTRACTORS DECLARATION DISTRICT No. PRO SED BY I hereby affirm that I am licensed under provisions of ChapTer GAS SYSTEM OUTLETS �� 9(commencing wiih Sedion 7000)of Division 3 of ihe Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM fINAL v��jl�� fect. DATE �/� r ` License Number�i�" �'�� Lic. Class ��Y�-� � v�`�� 7 / �i FINAL f� � Contractor� J�/1'Ic�/�'��ate / � /e' BY �1�f./� �, � I m e"�e�pf'��er 5�.�� y B.&P.C. for ihis reason Plan check fee � Date: PLUMBING PERMIT ISSUING FEE$ �(� �� Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant 1 •` ' .' ,�� I hereby affirm that I am exempt from ihe Coniractor's License Name ;:r. �� . L�� for ihe following reason (Section 7031.5, Business and ' " ssions Code): Address � �, �; � .` r;�� I, as owner of ihe property, wil) do ihe work and ihe City Tel. No. structure is not intended or offered for sale(Section 7044, Business and Professions Code). � r ,� _, �, � CONSTRUCTION LENDING AGENCY I hereby affirm ihat there is a construction lending agency for ihe perfarmance 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 ihis application and state that the above information is correct. I agree to comply with all County � ordinances and State laws regulating Plumbing, and hereby au ize represent '�es of ihis County to enter upon the � above- entione propert for inspecfion pur o es. ` ��l�� '� �, �� SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature of Permittee� Date