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HomeMy WebLinkAbout1308A 'WORKER3'COMPENSATIONDECLARATION � APPLICATIO(d FOR PLUMBING PERMI � •I hereby,affirm that I have a certificate of consenr to salf 7gpg67A . insure,or a cerlificate of Workars'Campensafion Insurance, CE 817(REV.8/88) or o certifpled copy ihereo 7(S_ec.3800,L1ab.C.) P❑olfty No4� ompany S7 COUNTY �F LQS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. a �� � � FOR APPIICANT TO FILL IN(PRINT OR TYPE) bUIL�ING Certified copy is filed wifh the coonty build�ng Inspac- ADDRESS � P nondepar�meM. NUMBER FIXtUREORI7EM � FEE L LOG4LITY �Q� . Date�AppliSanl +`S-e'+ WATERCLOSET OQ NEAREST � CERTIPICATE Of E%EMPTION FROM WORKERS' a BATH tue � CROSS ST. � COMPENSATION INSURANCE OWNER a (Thb s�cfion nwd�rot b�compl�»d if fh�work involv�d by SHOWER th�p•rmH ts for on�bu�dr.d dollon(Y100)or I•ss.) a LAVATORY � ��� ADDRESS I certify thaf in the performonce of the work for which this permit is issued,I sholl not employ any person in any manner SINK �ITY �� �-,_ s so as to become su6jed�o the Workers'COmpensotio�laws. OISHWASHER � C� CONTRACTOR ��� � - -� A�plicanr CLOTHESWASHER ADDRE55 C ,ICE TO APPLICANT: If, after making this Certifimte of � v�'S�- �mption, you should be<ome su6jed to the Workers' SWIMMINGPOOL�CEPTOR �ompensation provisions of the Lobor Code,you must forih- CIiV - ���� TEL.NO. �'�_ i�h com I wilh soch rovisi0�s or this LAWNSPRINKLERSYSTEM p y p permit shall 6e STATE LIC. n . deemed revoked. WATER HEATER � LICENSE NO. Q QASS C..r IICENSED CONTRACTORS DEGIARATION OiSTRICi NO. �ftocE55Eo ev I hereby affirm iha�I om licensed under provisions of Chapter 9 GAS SVSTEM OUTLETS (mmmencing wi�h Sec�ion 7000)of Division 3 of ihe Business OUTLETS OVER ����n �$ ond Professions Code,and my license is in full force ond affec�. 5 PER SYSTEM FINAL VALIpAT10N � license Num6er �r��v3 �ia Class�� DATE �' �/� Q ^� FINAL ,�j� 4 CoNractor l rJQ.� ate t-1-R 1 BY //'- v ❑ y 1 om exemp�Under Sec. 8.8P.C.for rhis reason � Plan check fee � � Date: ...� J��,�l� . PLUMBING PERMIT ISSUING PEE$ p J Signature ,� ` a " TOTAL FEE ' z @ 7��� Plon check applicant _ " � SINGLE FAMIIY � - =�/i;�:F)� " HOME OWNER-BUILDER DECLARATION Name eby affirm thal I am exempt from ihe Conhactor's Licanse qddress ����+?G��7 _ �,..,for.the following reoson�Section 7031.5, Business pnd Professions Coda): City Tel.No. ❑ I,as ownar of the propeny,will do tha work ond the � srructu�e is not imended or of{ered for sale (Section 7044,Busineas ond Professions Code). CONSTRUCTION LENDING AGENCY - I hare6y affirm tha�thare is e mnsrruction lending ogency for thc performance of 1he wook for which ihis ps�mit is issued (6e¢.�43,Ci�.f.�. . . Lmnder'a Name � Lender's kddess I cer�ify that I have read Ihis applimtion and sta�e ihat the ► � above infamation is mrrect I agrae la comply wilh all County . wdinancea and State laws.egalating Plumbing,and hereby au�ho�ize representotives of this Counfy 10 entx upon fhe obo�e•menrooed property for inspec�ion purposes. 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