HomeMy WebLinkAbout1555A WORKERS'COMPENSATION DECLARATION qPPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 76A667A PW 4/87 i
sure,or a certificaTe of Workers'Compensation Insurance,or a CE 817(REV. 8/86) �1 f
certified copy ihereof (Sec. 3800, Lab. C.) i t
r ✓ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No.���Company�a�����i�_ r� �`�
� Certified copy is hereby furnished. �� ` AJT�
❑ PY, Y g. P FOR APPLICANT TO FILL IN (PRWT OR TYPE) BUILDING �� � ����t,�n � ���
Certified co is filed with the count buildin ins ection ADDRESS p
deparf ent. NUMBER FIXTURE OR ITEM @ FEE �]
LOCALITI^�����ly-�� _ ���
Date � � Applicant WATER CLOSET(TOILET) NEAREST `J
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST��� f��j j- ����/�[,IDet �ji�
COMPENSATION INSURANCE sHOWER OWN`� _ ' ,y-� � � --�
(This section need nof be completed if the work involved by MAIL �
the permit is ior one hundred dollars (�100)or less.) LAVATORY ADDRESS� - � ',y7"�
I certify that in ihe performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CIT 7' r TEL. NO.- 4
�_.�j� �,�� )AL/J,��-az�/
as To become subjecT to the Workers'Compensation Laws. DISHWASHER _.----
CONTRACTOR � .� �„�`� G
_�a lG./ .
Date Applicant CLOTHES WASHER ADDRESS �'j �y�"�
N�TICE TO APPLICANT: If, after making this Certificate of Ex- S� ,� ��- ✓ J�J��
SWIMMING POOL RECEPTOR -
ion,you should become subject to the Wockers'Compen- ��'�-'i �/
CFfY �� � <P� TEL NO �7���",-�.:3'
s. .�n provisions of ihe Labor Code, you must forfhwith comp- / LAWN SPRINKLER SYSTEM � �-.� �
ly with such provisions or this permit shall be deemed revok- STATE �� LIC.
ed. WATER HEATER LICENSE NO.�_�C���-�� CLASS �- --��
LICENSED CONTRACTORS DECLARATION �ISTRICT No. PR SED BY
I hereby affirm that I am licensed under pravisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER �� ti'�����,
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATIOPI
fect. � DATE "
License Number�-���ea�n��Lic. Class��"� ���� � ���
�J/ �� FINAL
Coniractor �� � � �f���te � � gY �j-�'
�- !J. �y��-'C} �,���- /j,
� I am exempt�n�der'Sec. � ��,z��
8.&P.C. for ihis reason Plan check fee
Date: ►
PLUMBWG PERMIT ISSUING FEE$ �� t.�'�
Signature
TOTAL FEE ,..
SINGLE FAMILY � �� �f �� �; ;, �i
HOME OWNER-BUILDER DECLARATION P�an check applicant - ' �
I hereby affirm that I am exempt from the Contractor's License Name l' ' �
Lr for The following reason (Section 7031.5, Business and
ssions Code): Address e: F� �
i � G.`:a i=�
� I, as owner of the property, will do the work and the City TeI. No. . � � � -
structure is not intended or affered for sale(Section 7044,
Business and Professions Code). � � ;rr �� �� :_ __
CONSTRUCTION LENDING AGENCY
I hereby affirm that ihere is a consiruction lending agency for
ihe 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
-ize representat�.e�of ihis County to enier upon ihe ;
above- entioned pr perty�or inspection purpos s.
� _ �j ` �`;;�.f���,. '� �;� "�� SEE REVERSE FOR EXPLANATORY IANGUAGE
` igna ure of Permittee �� ate