HomeMy WebLinkAboutNo Permit Number (42).pdfWORKERS' C'OMPENSA'MON DECLARATION,
1 hereb3' affirm that 1 have if ccrtifiente Oi cmnsellt to Self
insure, ora certIficate of Workers' Compensation Insurance, or ,
s certified copy thereof (Sec. 5800, Lab. C.)
f
policy No_ -'-Company—_--.--_—._—_ .
Certified copy is here', turnis'hed.
crtified copy is filed —th the corm'' building inspection',
daplrl nrent.
Date_ _ Applici I —
CI:RT'1PICATH OP EXRhIPrION f'ItOM W(.)ItlCIA01'
I.
C OMPENSA'rioN INSURANCE
This section need not be completed if the xork involved,
by the pryrmit is for one hutldred dollars (5100) or 'ell,'
1 certify Limit in tiie performance of the wori, for which this
permit is issued, I shell not cin ploy any person in any munner
so as to become 5u bjecr to the Worl.ers' Compensation Laws.
Date_—__—.__ Applicant
4 NOili,'h 'r(i Ai2Fj,I(,ANT: ii, Mier inaldic, this f'L !item tc ml
f
P.ernption, you siloold betonn: subject rO the W'orkees'
Compensation pr I`iun, of tilee Labor Code, you lost forth
whir coolply with such provisions or this permit shall be
j((
deemed ...akcd.
L1('ENSED CONTRACTORS L)I:CLARATION
I hereby affirm that I :nn licensed under proviswms Of Chapter
E 9 (cO non
IswithSoctiou7000) of I)isiSion 3 of the R.=J
IE
mess and Professions Code, and my license is m full force and
effect.
License Number — —_ = Lie. Cines — — — — —
1 urn esempt trom rhe licensing requirements :+s 1 ant a
ed architect Or a registered profossiontd engineer
j acting in my professional capacity (Section 7051, Bus-
jjI
me.;s and Professions Code).
Lk. or lteg. No.
t!t HOti1R OWNER -BUILDER DT;( LARA'I ION
f hereb3 affirm Phot t am exempt from thu COntraci or's
I.icense Law fur the 9 )I >wing reason (Section 7031.5, Rus]
mess" and Professions C llde): ,
CJ I, :is owner of the: propertY. ;+m exclusively a•oalractingwithlicensedcontractorsfoconstructtheproject
Section 7044, Business anti Professions Code).
CONSTRGCfION LRNDINC AGENCY '
I hereby affirm than there is n conslrucflun lending agCTICY
for the pertorin-ce of the work for which this permit is
issued (Sec. 3097. ('iv. (=)--. ——.—_—.—.—_---
Lentfa• s Name_——.—
Lender's Add, ess_
I cerlify that I have read Ibis aPPlication mrd state that tiro
shove informatiOn is col rent. I agree, to comply with Ill Count)
ordinances and Stab laws repillaling Plumbing, and I—elly
authorize repiesentafivds of this Caunty to en;,r upon the
above.mentioned property for urspec(iou purposes.
Signanirc of Pe nniticc' -- I),I t
APPLICATION FOR PLUMBING PERMIT.'z
COUNTY.OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
MBER FIXTURE OR ITEM •
J
FEE
AJtlres _
WATER CLOSET—
LOCALITY L.—. --_—
BATH TUft
SHOWER ---
f
LAVATORY
OWNER
SINK- — —
DISHWASHER
InADDRESS
CITY ., TFL. NO.
CLOTHES WASHER_
SWIMMING POOL RECEPTOR
CONTRACTOR;''
LAWN SPRI N K L t ti SYSTEM
T
WATER HEATER ---
SYSTEM OUTLETGAS
OUTLETS
PER SYSTEM
STA I F_ r
LICENSE NO. - CLASS LS)
DISTRICT NO.
Plan check fee
PLUMBING PERMIT ISSUING FEE S
ITnTAL FEE _—
BUILDING
ADDRESS
AJtlres _
LOCALITY L.—. --_—
NEAREST ---
CROSS ST_
f A' OWNER
MAIL
InADDRESS
CITY ., TFL. NO. I
CONTRACTOR;''
ADDRESS
CITY _./lf,,, 1.—)__
TEL. NO.
STA I F_ r
LICENSE NO. - CLASS LS)
DISTRICT NO. PROCESSED BY I•
FINAL VALIDATION_
DATE —
FINAL
BY.— — --.
PI n check applicant
AJtlres _
Tel. No.
SIi C. Itb:V 1•:ItSF wlt EXPLANATORY LAN(iUAGp