HomeMy WebLinkAbout1219A -�7Z������� G��`�
� � WORKERS'COMPENSAiION DECLARATION APPLICATIQN F R PLUMBING I�ERMIT
I hereby,affirm that I have o certificote of consem�o self �g�gg�q �
insure,or a certificale of Workars'Compensotion Insurance, CE 817(REV.8/88)
or a cenifled copy theroaf(Sec.380f),Lab.C.)
����-�� �{..�_ r_, \ COUNTY OF LOS ANGELES DEWR. OF pUBLIC WpkRK3
PQol�icy No. o pany "�,�,' TVL'`Q ... '�r..4.:���., l�..
Canified copy is herohy furnishad.
� FOR APPUCANT TO FILL M(PRINT OR TVPE) BUIIDiNG j, � �
Cenified copy is filed with the coomy building inspsc- AD�RE55 V
lion deparlmenl. NUMBER FO(TURE OR IiEM � Fff ��Ai'.n,
�'� t WATER CLOSET
, Date ���' . � APPliqant � �� NEAREST
CER7IFICATE OF E%€MPTION FROM WORKERS' 6ATH TUB �1-�, CROSS ST. 1
V
COMPFNSATION INSURANC6 S�Q�R OWNER �
(Thfs�eNion n��d�wt hs eomplN�d if fh�work inrolv�d by
1M p��mit i�for a�hundr�d delfars(f100)or I�ss.) LnvATORv ���
Gy'(� ADDR SS
I canify�hat in the performance of ihe work for which this
permit is issuad,I shall not amploy any person in any manner � StNK � CI7V ��^� Q
so as to become subject to tha Workers'Compen50tl0��Ow3. DISHWASHER �
CONTRACTOR �j
�� r � ApplicaM ClO7HE5 WASHER .'T7 qDDRESS �
TICE TO APPLICAN7: If, ofier making fhis Certifica�e of SWIMMINGPOOLRECEVTOR �
.emption, you sho�ld become eubject to ihe Worke�5' ��Ty
Compensafion provisions of the La6or Code,you must forth- �qWNSPRINKLERSYSTEM + 'CC�''„ � c�L�
with comply with suth provisions or this permit shpll be STR7E - LIC.
- deemed revoked. WATER HEA7ER ��� ���EN��. `3 t� 3 C4455�,
LICENSFD CONTRACTORS�ECLARATION �ISTRICT NO. PROCE55ED BY
I hereby affirm thol I am liceased undsr provisians of Chaplsr 9 r GAS SYS7EM OU7LET$ ��, ` �
(commencinq wi�h Sacfion 700U)of Division 3 of ihe Business pUTlET50VER � 1 � � �
and Professions Code,a�d my license is in full face ond effea. 5 aeR SvStEn� FINAL C
�/�,g-,�" VALIDATION v
Lice�se Number�,3L�� Lic.Class�� �ATE �
'�+�,,� F1NA1 �
CoMroctor *��C �Dafe ���.' BY ��A� �
❑ I om exempt under Sec. �
B.BP.C.for this reason Plan check fee � �
oo�a: v'� � .` 1 2 1.9 R
PLUMBING PERMIT ISSUING fEE S
Signot�re
TOTAL FEE . ��.; ` • ° ` •5
_ Plon check applicant � � a��.��
� � SINGLE fAMILY
- '" HOME OWNER-BUIIDER OECLARATION Name r „ ` e �r��
,reby affirm that I am ezempt from the CoMractor's licenae - qddross � z
, ...w far�rhe following reason(Secrion 7031.5,Business and � 0�'..,,�� —8']
Professions Cods): Ciiy Tel.No. .
❑ I,as owner of fhe property,.will do the work and the
slructure is nat inlended or offered for sale (Secrion �
7044,6usiness ond Professions Code).
CONSTRUfTION LENDING AG€NCY
I hereby affirm tba�there is a constrodion lending agancy for
the performpnce of t1y work for which fhis permit is issued .
(6�.3Q41;�i�.E.). �
La�dnr's Nome
Lender's Address � �
I certify thot I hove read�hiz opplicotion and stote that the � .
� obove infwmufion is correct.I ogree to comply with oll County ,
ordino�ces ond State laws reguloting Plumbing,and hereby �
1ho�ize repre�enfWive f rth' Co ty 10 enter upon ihe �
ove� ention ! r � r i e �on pJ�tyb�siqa.n ,r,� SEE R6VERSE FOR EXPLANATORY LANGUAGE
t!��`-'�-�'
rrohrre of Perminee Daro C - - .
�+t^'-: - .� .
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