HomeMy WebLinkAbout0367A WORKERb'COMPENSATION DECLARATION
APPLICATION FOR PLUMBING PERMIT ��, �
I hereby affirin 1ha� I have a certificaie af�onsent to self �pq667q � ����
insure,or o ce�tifimte of Workers'Compensa�ion Insurance, CE 817�REV.10/ei)
or a ce�r4ied mp thereof(Sec 3800,Lab.C.) COUNTY OF lOS ANGEIES BUILDING AND SAFETY
PT�1P�62313�89 ComPoFremont Indemnity � A ��. �.
� Certified copy is here6y furnished.
FOR APPUCANT TO FIIL IN(PRINT OR iYPE) BUILDING��x � ��
Certifiad mpy is filed wilh ihe county ilding ins e ADDRE55 LJ
7iondeparlmenl. NUMBER FI%TUREORITEM � FEE �Q���TM
DO1e 7/31/86 AppliGanlRCR U�7 WA7ER CLOSEi �f NEAREST ,
CERTIFICATE OF EXEMP7IQN FROM WORKERS' � BNTHiUB , CROSSST.GOZdeIl Springs/Carpio
COMPENSATION INSURANCE SHOWER OWNER � �
(This socfion nood net b�complN�d if iho work involvad hy . MA��
th�p�rmi�Is ior ono hundr�d delfan(5100)or Ins.) IAVATORY qooaeSS 1� 4� Park View
1 certify�hat in fhe perfo�mante of the work for which this
permit is issued,I sholl nol emplay any person in any monner / SINK � .�• CITY TEL.NO.
sa as to become su6jecf to ihe Workers'Compensalion laws. DISHWASHER
CONTRACT
���g 0 IiCOM CIOTHES WASHER �'-
Pp P ADDRESS 12785 Ma nolia Ave.
�710E TO APPLICAtJT: If, after making ihis Certifimte of
� Ezemption, yo� should become subjocl �o Ihe Workar5 SWIMMINGPOOLRECEPTOR CITY TEL NO.
. Compensation provisions of the Labar Code,you musf fo�ih- LqWNSPRINKLERSYSTEM
with comply with such provisions or �his parmit shall be STATE • LIC.
� deemed revoked. WATER HEATER �iCENSE N CtASS —
j LICENSED CONTRACTORS�ECLARATION DISTRICT NO PROCE55eo ev
'� I here6y o$irm lhat I om licamed under provisions of Chapter 9 G.455VSTEM pUTLETS � � � ��
� (commencing wilh Saclion 7000}of�ivision 3 0£ihe Busine5s OUTLETS OVEF
ond Profassions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
�o,re I� 2y � VALIDATION a,
license Number 33fi428 �ia Class C-36 p
co�,�a«o�RCR Plumb ing oa Q 7/31/86 gY'4� ,%2£,,,., �
. � o
1 am exampi under Sec. U
8.8P.C.for this reason W
Plan check fee ► �
� Dote: PLUM8ING PERMIT ISSUING FEE$ �
Signafure �
TOTAL FEE •�'n���,�J�,
Plan check applicani $;�� e • �a e 5
, � SINGLE FAMILY
� HOME OWNER-BUILDER DECLARATION Name ' ' ._ ���,5�
I heraby affirm Ihar I om exempt from the Conhactor's License Address
Law for the followi�g reason(Section 7031.5, Business ond � �„ , ,;{��.�;j C�7.
Professions Code): Ciry Tel.No.
❑ I,os owner of ihe property,will da ihe wark and the ��'�.C�'`���J
structure is not inrended or offered fo�sale (Section � -
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY .
I hereby offirm ihat there is a consiruction lending agancy for �
the parformonce of ihe work for which this permit is issued
�See.�97,E�w.6.).
E'C�E�'S RCflF�
L•Brttibrs F.1fdP97S
I<e�ti4y�ha�I have reod this applimrion and stare thot the , .
above informafion is corretl.I agree to comply with oll County
ordinonces and Stale laws regulating Plvmbing,ond hereby
authorize re e'sento�ives of this County to enter upon Ihe
ohove-men o ed pro fy i spec�ion pu poses
RCR By: � 7/31/86 SEE REVERSE F�R EXPLANATQRY LANGUAGR
Signature of Permittee Date �
� �� �'�`
, ti � _��r ��.�~`.�� ...r� .
AvaROVnLs oATE iNSa�CtOR'SSiGNnTUae INSPECTOR'S NOTES O�NNE?.-BWLDER DECI..4RATION. �
UNDER StAe WORK � ��r �'f��� - I hereby afflrm ihot I om exempt from Ihr Coetrccror'a
ROUGHPtUM81NG License Law for the following reason (Se<lion 703i.>
GAS PIPING ' � Business.ond Professfons Code;:Any city or covnty wh�ch
GAS VENT
requires a permii fo conslrucL aifer,improve,demofish.
. or repair any strur}ure, prior fo i15 issuonce, also re-
HOT WATER HEATER . quiras the appfimnt(or such permif fo file a signed srnfe�
PIUMeING FlXTURES � menh Ihat he is licensed pursuan;lo fhe provisions oF}fre
GASTE57 m� � Confracior's License Caw/Chap�er 9(commencrng v�i;M
UTILITY CO.NOTIFlED � � ____ _ Section 7000)o(Division 3 of Yhe 8us)ness vnd Profes-
, � sions Code)or fbaf Re is exempf}herefrom ond�he basis
fc7 for ihe alfoged exempfion. Any v'rolaHon oi Setlion
� FihAL L (er on ,}ronl � 703L5 by any applicani/or a permif su6jects fhe appll-
. . . cant to a tivi!penalty oi not mare tbon five hundred
dollars(SSOD).:
INDUS7RIAL � . ❑I,as owner cf the prope�ty will do ihe work ��1
WASTE APFROVA�_ �� � - - the shuctura i:not intended or offered for sale.
(Sec.704�.Buslness and Pro/essions Code: 7heConfroo
� tor's Lltonse Law does not apply fo an owner of properry
. , � .� . � wbo boilds or(mproves thereon, and who does such
� � � work himeeff provfded thaf soch improvemenis are nm
lnfended or offered 1or safe.If,howerer,the bullding or
� Improvement 1s so7d w1lbin ooe year o/completiort,the
owner-bulfder wi7!have fhe burden of proving thot he did
nof 6ufld or fmprove/or the purpose o/sole.)
I am exemp!under Sec. ,
B&P.C.for ihis reason
Date
Owner
IhISPECT�R'S Nt�TES