HomeMy WebLinkAbout1556A WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
20-0026 DPW 4/87
I hereby, affirm that I have a cerfificate of consent to self in- `
� �
sure,or a certificate of Workers'Compensation Insurance,or a CE 867(REV. 8/86) ° 1
certified copy thereof (Sec. 3800, Lab. C.) � �
��� � COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. �� Company '� ���A'���-���
� Certified copy is hereby furnished.
�"�>� 1��� �
FOR APPLICANT TO FILL IN (PRWT OR TYPE) BUILDING �
� Certified copy is filed wifh the county building inspection ADDRESS � ��� ��� ��, �_ �`(����
NUMBER FIXTURE OR ITEM
deparTment. @ FEE LOCALITY�J`�/J�IY��� `�7�`�_'
Date �� � �� Applicant WATER CLOSET(TOILET) NEAREST� F ' �-lJ
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRo55 5`��/!�"�)t7�� ��.}� ��f�r�,C� �, 1
COMPENSATION INSURANCE SHOWeR �'N R ?�.�� �/.�/�_'/�.�/ y�,�
(This section need not be completed if the work involved by MAIL � ,�i
the permit is for one hundred dollars ($100)or less,) LAVATORY ADDRESS���� ��/reGG�,�-J �(�f �T� ;
I certify that in the performance of the work for which this per-
mit is issued, I shall nof employ any person in any manner so SINK CITY��j�=T� Y���� TEL NO.��,,� �/'�/a�
as to become subject to the Workers'Compensafion Laws. DISHWASHER � /
coNrRa,croRE Y,�'/�f � _,t��.��``�,��"����G_.`�
Date Applicant CLOTHES WASHER ADDRESS r,� / �`�
NnTICE TO APPLICANT: If, after making this Certificate of Ex- �i l � - /�� ✓���„
'ion, you should become subject to the Workers'Compen- SWIMMWG POOL RECEPTOR
s. .�n provisians of ihe Labor Code, you must forthwith comp- CI7Y�—� ��_ � ��-g� TEL. NO�f,,I��
LAWN SPRINKLER SYSTEM -`�--�� �/-,���Y���
ly with such provisions or this permit shall be deemed revok- � �� STATE � uC. - y�
ed. WATER HEATER LICENSE NO. ���Ci/,���� CLASS �� %
LICENSED CONTRACTORS DECLARATION DISTRICT No. PR SSED BY
I hereby affirm ihat I am licensed under provisions of Chapfer GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of ihe Business OUTLETS OVER � � �,�°�'.'p'd�-�
and Professions Code, pnd my license is in full force and ef- 5 PER SYSTEM FINAL VALIDA I I8I1I
fect.
DATE �_�-���
License Number���' ��� Lic. Class ���'�
/�' / FINAL �
Coniracfor/ ��//�g�/��1�f�'=-�I�,�ate � �'� �� BY �;�__
❑ ��P��/ �� m��
I am exem f under Sec.J���'�— Y J�
B.&P.C. for this reason Plan check fee
Date: , ;�,
PLUMBING PERMIT ISSUING FEE$ �� � �
Signature � ,_
TOTAL FEE ��, �"� � � -- •� , � _.
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION P�an check applicant � ,. :,, � ,-', ,
i hereby affirm that I am exempt from the Contractor's License Name ,
Lr • for The following reason (Sedion 7031.5; Business and
ssions Code): Address
l� (> �
� I, as owner of the property, will do the work and the City Tel. No.
strudure is not intended or offered for sale(Section 7044,
Business and Professions Code). �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending 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 that I have read this application and state that the
above information is correct. I agree to comply with all County �
ordinances and State laws regulating Plumbing, and hereby
aut ort e repres ' s of this County to enter upon the
above�entio d prop ty for inspecTion purp ses.
� � � � SEE REVERSE FOR EXPLANATORY LANC'sUA,GE
i �
Sign ture of Permittee Dat