HomeMy WebLinkAbout11_10_1982 - 2016 PEACEFUL HILLS RD WORKERS'COMPENSATIONDECLARATION �sasww � .
I hereby afPrm �hat I have a'rertificate ofrnnsent toself� ce.,,,2-ea, � APPLICATION FOR�PLUMBING PERMIT , .
insure,or a certificate of Workers' ompensatton Insurance,or . �- � � � � � -
ce hfied coDY ther ot(Sec. BO�LYK. . . � �
/�fd �- lfp�'-JO�� ���� COUNTY OF LOS ANGELES BUILDING ANDSAFETY y
`-'FoTcy o. company ��--� 3- � �p2.1�'/�
� Cmti copy is here6y furnished. FOR APPUCANT TO FILL IN(PRINT OR TYPE) BUILDING �
Certified copy is filed with the county buildtng insp ction NUMBER FIXTURE OR ITEM • FEE ADDRESS `
department.j,� - �� � WqTER CLOSET _ �I LOCALITY . •
Date,Cf�0" ADP��cant � ��V NEAREST �
�' BATH TUB CROSS ST. - - �
CERTIFICATE OF EXEMPTfON FROM WORKERS' �
COMPENSATION INSURANCE SHOWER OWNER � � .' �
(This section Reed not Ue cOmpleted if the w0[k invOlved IAVATORY ADDRES �
by the permit is for one hundrod dollars (S100)ar lees.) f SINK � - p� �'��' a
/ � � CONTRACTOR < r��`TEL NO.� _ � O
— 1 certity that in the performance ot the w�rk for which this DISHWASHER V � —
permit is issued,1 shall not employ any person In any manner �,��
- so as lo become subject to the Workers'Compensation Laws. � CLOTHES WASHER - -
� ADDRESS /3�J�'� � ��l � O �
Da[e Applic�nt U �
� SWIMMING POOL RECEPTOR
NO" ��TO APPLICANT:If,after making Ihis CerliCcafe of CITV �TEL.NO. �� W .
F:[• �on, you should become subject to the Wnrkers' LAWN SPRINKLER SYSTEM STA7E p� LIC. �
Compensation provisions of the LaM1or Code,you must forth• VyATER HEATER � LICENSE NO. �S A CLASS �-� Z
with comply with such provisions or this permit shal� be —
deemed revoked. �� �ISTRICT�. HOCESSED BY .
� GAS SYSTEM OUTLETS � � .
LiCENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby atFirm that I am licensed under provisions of Chapter 5 PER SYSTEM '�S� .
9 (Commenting with Section 7000)of Division 3 of the Rusi• - -J FINAL AUDATION
ness and Professions Code,and my license is in full force and GT� OATE �A �
effect. y
.G
LicenseNumber_L_L_.7�LC�_o LIc.Class `� —� - FINAL -_ � � �
�,,//ffJ��� �,,//���_ p BY
Contractorf� Date ��;/� -'G � , ' , •
� I am exempt from ih licensing requirements as[am a Plan check fee
licenud architect or a registered professional engineer pLUM61NG PERMIT ISSUING FEE$ . � �
�acting tn my profe.ssinnal capacity(Section 705�, Bus- d ' . . .
iness and Professinns Code). TOTAL FEE _�'j Q�v ' . � �
Lic.oY Reg.No. Date Plan check app�icant �
HOME OWNER•BUILDER DECLARATION � Name . � � � � � �
..-----�- -_.--- --..__.. . ._. .. __ . .__-__ __�__-- ' -------._ _..' -
____.__.__. . . .
.. .. .__.. _ .. _ _.._. _ _.__ ._ .. . . - ----..._ ---------- _ . ..
I h ty affirm that I am exempt from the Contractor's Aaerecs � �4 2�J�
Lic. J Law for the foliowing reason (Section 7031.5,Busi- Cky Te1.No.
ness and Professions Code): TM��� � � �F .
� I,as owner of the property,am exctusive�y conhacling
udth licensed contractors to construct the projec[ _ . �� • � Q?C�Q .
(Sedion 7044,Business and Protessions Code). . . - . . .. . .. . .
� . ° • � V 7.n L u
CONSTRVCTION LEND[NG AGENCY . ._ .. . . . '
I herehy affirm that there Is a construction lending agency - � �
for ihe performance of the work for which this permit is � � �,� �j—b'�
issued(Sec.3097,Civ.C.). � �� - -
LendePs Name - . ' .
Lender's Address � �
I certify that 1 have read this applicntion and state that the � . � � .
above intormation is conect.I agree to comD�Y µ'ith all County � 5EE REVERSE FOR EXPLANATORY LANGUAGE � � -� � �
ordinances and State laws regulating Plumbing, and hereby
authorize rcpresentatives f this County M enf�t uppn the , '
above-mention d proper for inspection purposes. . � - � �
,��• �-�.�' l/-/a �Y
� gnature ot Permittee Dete
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