HomeMy WebLinkAbout1230A WORKtiRS'COMPENSATIONDk:CLARAl'ION �••.e�^ APPLICATION FOR PLUMBING PERMIT `jl �
I hereby affirm that ( have a certificate of consent to se�P ee�n(z•ao� �
insuce,or a certificete ot Workers'Compensation Insurence,or� 1 1
a cerHfied copy ihereof(Sec.3800.Lab.C.) 1,,,1 �
poticy x��.���v ��A �' —����G COUNTY OF LdS ANGELES BUILDING AND SAFETY
mpany ��1
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PFINT OR TYPE1 BUILDING
ry ADDRES3 tj
�yT _Certified copy is filed with the county b ilding insp C rt NUMBER FIXTURE OR ITEM • FEE �
"�'��i [ LOCALITV
Date �' Appliwnt WATEF CLOSET
NEAREST
BATH TUB CflOSS ST. r
CERTIFiCATE OF EXEMPTION FROM WOR
COMPENSATIONINSURANCE SHOWEF OWNEFi �
LAVATORY MAIL
(This section need not be completed if the work invoired ADDRE55
hy the permit is for one hundred dollars (5100)or less.) }
SINK p7y TEL.NO. �-
I cer[ify that in the performance of the work for which this V
permit is issued,I shall not employ any person in any menner �ISHWASHER CONTRACTOR � I Q.I
so as to become subjec[to the Workers'CompensaUon Laws. � --H� �
CLOTHES WASHER qDDRESS 0
Uate Rpplicant b F,.
SWIMMING PODL RECEPTOR
NOTICE TO APPLICAN'C:If,after making this Certificate uf CITY '�°� TEL.NO ��, V
Exemption, you should become subject ro the Workers' LAWNSPRINKIERSVSTEM �j a
Com ensation STAT LIC' �_� Z
p provisions of the Labor Code,you must Purth- WqTER HEATER LICENSE NO.n� CLA35
with complv with such provisions or this permit sholl be
deemedrevoked. GASSYSTEM OUTLETS DISTPICTNO. PROCESSEDBV
LICENSED CONTRACTORS DECLARAT[ON I � �
OUTLETSOVER ll � C� �,/
I hereby afFirm thet[am licensed under provisions of Chapter 5 PER SVSTEM
9 (commencing�vith Section 7000)of Divislon 3 of the B�si• FINAL
ness and!'rofessions Code,and my license is in full(orce and �ATE VALIDATION
effect.
License Number�y�S�, Lic.Class C�`� �
�� �,�� BY
Contractor���.""_`'"� Date q—���-�� . .
� I am exempt from the licensing requirements as I am e Plan check fee
]icensed architect o[ a registered professional engineer pLUMBING PERMIT ISSUING FEE$
acting in my professional capaoity (Section 7051, Bus-
iness and Yrofessiona Code). TOTAL FEE a t) �r, �?C�`� �
Lic.ur Reg.No. Date Ptan check applicant � '+R� )���
HOME OV+NER-BUILDER DECLARATION Name . � ' �
• � <..F. i:c
:�,i i —°�
I heretry a[firm that I am exempt from the Contractor's Adtlress - �
License Law for the following reason(Section.7031.5, Busi- Citx Tel.No. ��=T ="�.: T Fi
ness and Professinne Code): .
� , . .'r e�a ��
I,as owner of the property,am exclusivety contracting
with ticensed contrectors to conetruct the project
'(S�t�n��'�s4�Esc0ri0.�rriLENlnasi#sdt). .
CON3TRUC7I6N LENDING A6LT[CY
I hereby affirm thet there is x construction lending agency
for the performance of the work for wh5ch this permi[ is
icau�{5ec.3P9?,C1v.C j.
Lendar's Name
Lender's Address
I cettify that I hxve read thia application and state that the
a6ove information is correct.I agree to comply svith all County SEE REV ERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws reg�lating Plumbing, nnd hereby
authodze represent�tives of this Counq� to enter upon the �
above-p �doned pfop y f r Ip t4on purpems. .
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