HomeMy WebLinkAbout1250 KING LAKE DR (2) WORKERS'COMPENSATIONDECLARATION , oueevw
I hereby affirm ,hat � have a'certificate o��o�b�t�o,e�f : ��.,,,,-.o, APPLICATION F4R'�PLUMBING PERMIT �
insure,or a certificate of Workers'Compensation Insurance,or i . � '. n �
a cerfified copy thereof(Sec.3800,Lab.C.) � - . G�
COUNTY OF LOS ANGELES BUILDING AND SAFETY �i
Policy No. � Company � �
� CertlFied copy is hereby furnished. FOR APPLICANT 70 FIL�IN(PRINT OR TVPE)- BUILDING � � � �
� ADDRESS
Certlfied copy h flied with unty b 'Iding inspection NUnaeER FIX7l1RE OR ITEM • fEE
d m t. � � LOCALITV �
Date Applicent WATER CLOSET NEAREST �
/� . BATHTVB CHOSSST. /C/�.'��✓r:•-�/�'�`'`�JSi�: ,
' , CERTIFICATG OF E]CEMPTION FROM WORKERS'
. COMPENSATIONINSURANCE SHOWER OWNER
�, (This section need not be completed if the wOrk invOlved LAVATORY qODRE35 1 d� �
by the pem�it ia for one hundred dotlers (5100)ar tess.) SINK }
pem a
I ; � CITY - TEL.NO. � .—
I certify that in the pertormance of fhe work for which this 9 U
1 DISHWASHER
permit is issued,I shall nnt emplo any person in eny manner CONTRACTOR
�
so as to b w e subject to the or ets' pe ation Laws. CLOTHES WA9HER A��RE$$ �
Dat�APPlicant SWIMMING POOL RECEPTOFi , � w �
NOTICE TO APYLICANT:it,after ing this Certificate of CITV; TEL.NO. (�2!��'�D �
F.zemption, you should become suhJect to the Workers' LAWN SPRINKLEN SVSTEM� /� {q qp �
Compensation provisians nf tfie Lebor Code,you must forth- WATER HEATER LIC N$E NO."o�I 10 !6 C'C L
wilh comD1Y W'ith such provisions or this�permit shali be — '
deemed revokeJ. � � GAS SVSTEM OUTLETS OISTR�NO. PROC SED BV
LICF.NSF.UCONTRACTORSDECLARATION OUTLET50VER � C.z�-y) .
I hereby affirm that 1 am licensed under provisions of Chapter 5 PER SYS7EM
9(commencing with Secfion 7000)ot Division 3 ot the Busi- FINAI
ness and Professions Cnde,end my license is in fufl torce and DATE _/C_4 Z VALIDATiON'.P
ePfect.� � � -
�QqQ. G'`36 FINAL r ': • • • ��
L{cenae Number 1JS1_ Lic.Ciass gy �
Contractor ete /��+Z� f �•� � ?r C
� I am ezempt fr the licrnsing requimments as I am a Plan check fee •'" `1 �i��-
licensed architect or a reQistered profeuionfll en�ineer pLUMBING PERMIT ISSUING FEE S �
acting in-my protessional capacity (Section 705L,Bus-
iness and F'rofessions Code). TOTAL FEE 2 '�7�?n—�`�
Lic.or Re'g.No. Date plan chack appliunt
HOME OWNER•BUILDER DECLARATION Nama � � �
I hereby affrm that 1 nm exempt fmm the Contractor's Addraet _
License Law for the follawing reason(Section.7031.5,Busl- Cky Tel.No. '
ness and Professions Code): • .
�� 1,as owner of the property,am ezclusively contracting � ' -
with licensed coNractors to construct the project �
(Seclion 7044,6usiness and Professions Code). _ . -
CONSTRUCTION LENDING AGF.NCY " ����i� ;/�n ��r��� ������� �
I hereby affirm that there is a construction Iending agency ��i,i,'f�� = �6r E+ i,�' 0`. �
for the performance of the work for which ihis permit is ddi � ] j �
issued(Sec.3091,Civ.C.).
LendePs Name �
Lender's Address �
1 certify that I have read this application and state that Ihe �
above information is correct.1 agree to comply with all County _ SEE REVERSE FOR ERNLANATORY LANGUAGE
-ordinances and State laws regulating Plumbing, and hereby . , �
au[horize resentatives of this County to enter upon ihe
above- n' ned p rty for inspection purp ses. � � � �
� ��/,�X�/?� � , . . . ,
Signa[ure rmittee Date � .
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