HomeMy WebLinkAbout1527A WaRKERs'COM1 �cONDECLARATION ��Ass�a APPLICATION F4R PLUMBIN r
� I hereby sffirm that I haCe a certificate of conseJ�t to self cc en(a-eo�
� Insure,�or a certi$cate of Workers'Compensetion Insurance,or � . .
��� �a certified capy theceof(Sec.3800.Lab.CJ COUNTY OF l05 ANGELES BUILDtNG ANU SAPETY
Policy No. ��� Coropan� �
I �Certified opy is hereby fur 'h FOR APP�ICANT TO FILL IN(PRINT OR TYPE) BUILDING � t"� '
AOORE9S �
Cer fi c.ppy is filed wit t c nt u' i ns ection NUMBER FIXTURE OFi ITEM � FEE
f�� LpCAUTV �
b��.- WATER CLOSET �
Date Applica NEAREST
� � BATH TUB CROSS ST. �
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE 5HOWER OWNER
LAVATORY MAIL
� (This section need not be completed if the wock involved nooRESS
� 6y the permit is foc one hund�ed doUazs ($100) oi le56.� SINK 0
. CITY TEL.NO.
1 cerNfy that in the performance of the work for which this DISHWASHER V
ye[mit Ls issUed,T shall nOt emp�oy any person in any manner � CONTRACTQR �
� so as to become suBject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS B9 � O
, Date Applicant SWIMMING POOL RECEPTOR � �1 V
, NOTICE TO APPLICANT�IS,after making this Certificate of CITY TE4.NO Jp�a' a
� Exemption, you shouid become su6ject to the Workers' LAWN SPRINKLER SVSTEM t,n
CompensaHon Provisions of the La6or Code,you must forth- STATE �../�� ClASS C `3 z
with comply with such provisions or this permit ahall be WATER HEATER LICENSE NO, —
deemed revoked. � GAS SVSTEM OUTLETS DIBTRICT ND. PqOCESSED 8Y
� LICENSE�DCONTRACTORSDECLARASION OUTLETSOVER CC� Rt.W-✓
� I hereby affirm that 1 am llcenaed under provlslons of Chapter 5 PER SYS7EM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAI. VALIDATION
. ness and Pr ssions Code,and my license is in fWl force and OATE � 'g`��
effect.
FINA
� License Lic.Class C � . BY ^ �
Contra
', � I am exempt from the licensing requirements as I am a Plan check fee � -
� licensed architect or a registeted pmfessional engineer p�UMBING PERMIT ISSUING FEE$ !` �
acting in my professioaal capacity (Section 7051,Bus-
iness and Professions Code). TOTAI.FEE �d�
Lic.or Reg.No. Date Plan chack applicent - �� ,rj'Z,].A
� HOMEDWNER-BUILDERDECLARATION � Name � �� �,� .,Jr
I hereby aFfirm that I em exempt from the ContractoPs Address � �� • � � 2�5�
� License Law for the following reason (Section.9031.5,Busi- CRy 7e1.Na � - �
ness and Frofessions code): •• •� 2,5�_
❑ U
I,as owner of the property,am ezclusively contracHng
with licensed contractors to conatruct the project . O P,� O`$2
(Section 7044,Business and Protascions Code).
CONSTRUCTION LENDING AGENCY � � .
I hereby�affirm thet there is a construction lending agency
for the performance of the work 4or which this permit is
issned(Sec.3097,Giv.E.)• .
� Lender's Neme
Lender's Address '
[certify that I have read this ap licetion and atate that the
� above inf tion is correct. e to compiy wi[h all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordirtan a d State 1 e ula ing Plum6ing, and hereby .
� author' re ese ativ is ounty to ent r pon the .
� ahov ti neA o t ins ction pUrpose.
�
Signature of Pmmittee Dete
. ; -. s .� � . . . . .. _. _._. .. . ...., �.. _ . . .
./� ��� ����• a�i� —_ _ '— ��� a �'�!
Y !
APPROVALS DATE �IN51'ECTOFSSIGIVATUI7E INBF€Cl`QR�S fVOT@8 OWr1�R-B�I��.DE'R�E�IiARA7ION
UNOER SLA6 WORK � � .
ROUGH P�Un4BING � � � � � 1 hetsby a€�arm tMt I am ezempt from the Contrac[oi s
—.._—_—.—_..—.._——_--- . �Lisense�La+v f� Me��fa>Flawind reesen/9retien 7@31.5.
.3aS Pi�inlG �_� _ _ _ � � Business and Projeseia+�s CodeJ: Any crty or codrtty
ca5 vENT . � � � which requires a�perrnit to construct, after, Hnprove,
I-IOT VJATER HEATER �� ' d87i1B� 61'7'BPiI�OO$'BFRW.'f1Y'4 PX��'ta!ti I&81WWl:B,
— aFso reqerires.�Nze eWpllrent jor sr�ch-.�rmr! ro jltr a
PLUhABIRG FIJETURE� � ' � Sf�'!� SfWaIMCM!! YJMf� +fE Cf I16BM42(//MfI'SMH!!f t0 fI1P
GAS TEST � ' JN'OVtS:OYlS af thF CoNtIttCtDlS LlfEn9F LOW/C/mpter 9
uriU�rv co.rvoriFiEo - (camme+�e+nd xvfh SYr�iuro 70BdJ of l�tri�n .3 of the
. . — .. Business a»d A»feasi�xa Cadr/ or tAvt he ia exemPi
�INAt tlterejrone o+�d the baris for the afkged exemprion..4ny
�v'� We ���- viulati�+t oj Svarwn 70.31.5 by awY�f�r a Prrmit
�` ._.—... ..- ----—�- subjects!he appH'can7 to a civil pe�mhy of raor more than
�tvouErr,iaL � . fixelerndredd��ihn�s(£SABI.:
�WaSi,vE qa�r�.3VAt� � � � Q I,as owner of tl�Pro�ety wiFl do the aork,axd
the slrueture is n�t iaienAe�t or otfafe8 ior s�le.
, . � � � - (Sec. 709-f, BaMiness m�d Rr�e.sieas Cods: Th¢Con�
� � � ' `- . � � truetor'a Lrcense�Law doa.r rret appfy ro ar ouv�er of
. . . ., � � propet7y.w�lro M�ikls w improres therrevn,a+d w!ro dr�es
. - - � � � � .rneh work hirnself proui�hpd thet sach ix�rovamwrEs
. . . . - � . ore nar intersded or u!lered jer s�. Ij, lcawe+�er, dre
� � be�lkling or ixproi+er»eHt it .s+dd within wre yrw oJ
� corry�eriat, rhe or`voew�(eiar wiH imve the burdcn
� � " � � �� � af prorire�g thnt he did not buehl ar irnprove jor the
P�++Y�se of saAe.J .
I am exempt usicler 9�c. ,
B$P.C.fof this reerue�t
I�te
Owner
. ,:IWSPECTOR'S NOTES � .
i