HomeMy WebLinkAbout7104A.pdfWORKERS' COMPENSATION DECLARATION
20-0046 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I am exempt from the Contractor's License
I hereby, affirm that I have a certificate of consent to self in-
Compensation Insurance, or asure, or a certificate of Workers' Com P
7
CE B1( CE 81 7 (REV. 8/86) 1
Professions Code): Address
certifie o 1h4c f Lab. C.)
City Tel. No.
Business and Professions Code).
S df380, 60to"'C COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS .
I hereby affirm that there is a construction lending agency for
Policy o. ompany
he performance of the work for which this permit is issued
Sec. 3097, Civ, C.).
Certified copy is hereby furnished.
Lender's Address
I certify that I have read this application and state that the
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Z3 &65
ordinances and State laws regulating Plumbing, and hereby
CertifiedCertified copy is filed with the count uilding inspection
deportment. ". NUMBER FIXTURE OR ITEM @
ADDRESS *QC641N
FEE
LOCALITY
SEE REVERSE FOR EXPLANATORY LANGUAGE
Date_ Applicant WATER CLOSET (TOILET)
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS SL
COMPENSATION INSURANCE SHOWER -
OWNER
U2 BO Zt& This section need not he completed If the work Involved by MAIL
the permit Is for one hundred dollars ($100) or less.) LAVATORY - - ADDRESS
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 EL. O.'
as 10 become subject to the Workers' Compensation Laws. DISHWASHER CONTRACTOR
Date Applicant CLOTHES WASHER
ADDRESS
x- NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ememplion,'you should become subject to the Workers' Compen- SWIMMING POOL RECEPTOR'
V
Q
sation provisions of the Labor Code, you must forthwith comp• LAWN SPRINKLER SYSTEM CITYSrl. Via TEL N 1.
ly with such provisions or this permit shall be deemed revok- STATE Uc. 7
ed. - - WATER HEATER LICENSE NO, CLASS J
LICENSED CONTRACTORS DECLARATION
GAS SYSTEM OUTLETS
DISTRICj NO. _ PROCESSED BY
1 hereby affirmthatI am licensed under provisions of Chapter I\) A\1\ 9 (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER v-
and Professions Code, and my license is in full force and of- 5 PER SYSTEM - FINAL // (/ VALIDATIONfec1.
LL Lit.
DATE (p- .2-If a
VLicenseNumberClosscli,_
Contractor , Dor_
FINAL
BY
I
OI—
I am exempt under Sec. W
B.BP.C. for this reasonP lan check fee
LU
Z
Dare: PLUMBING PERMIT ISSUING FEE S
Signature TOTAL FEE I I rRr)
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Low for the following reason (Section. 703 1.5, Business and
Professions Code): Address
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sole (Section 7044,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
he 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
authorize re en 4 (les of this County to enter upon the
above -me ne /open tori spedion purposes.
ee Date
SEE REVERSE FOR EXPLANATORY LANGUAGE
X71 0413
IBe1650
16505
0u21-88
Z T
Z c4 O r S O O m cAo
m r
in
m
c ai vni c
O
o
rn
4
D"37
cC1 N OZ m2 v 2 9N A
vVDrTs
2 0 r
m x
Nz
v
m
CA
m
Z ,
cnDm
O
to
Z
O
mN
r 'sm G
O '
VC (nom (JI OrO
4D 9b
d 'gym me u, _ at
3tO a2 o.mmS,o ao Optel• NZ, !R
mmr,.. Ig mo
m$
B O 0 * . o- •
Q p ! 0 -•
O `' _. •.
p • to .. C0 O' .O 4+ ID O
Y ZCnUb% G d coOOh
D AE?:
OL i 9L 9 CL m4 y m tv+a