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HomeMy WebLinkAbout1311A � WORKERS'COMPENSATION DECLARATION AppLICATION FpR PLUMBING PERMIT ^ ,I hereby,affirm fhat I have a certificata af consent to self 7gpg87A ✓1 1 insure,or a certificpte of Warkers'Compansation Insuronce, CE B17�REV.8/88) � V or a certiftie�d copy�hereof}�.3800 LQb._C.) n O�yNov"1834�1�"' �y'�T�t� �'t�I� COUN?Y OF LOS ANCiELES D�PT. OF UBLIC WORKS Cert�fied copy is here6y furnished. a� ` � � �, iOR APPLICANT TO FILL 1N(PR�NT OR TYPE� BUILDfNG � 2�� P - Cerrified mpy is filed with ihe county 6ulldin9 Inspeo- ADDRE55 �ion depar�menl. ( NUMBER fIMURE OR ITEM � �E �p�qpTV � �yt,p � ' �e ((,,,��� WA7ERCLOSET 1 � Dote Applitont � �� NEAREST 1 CERTIFICATE OF EXEMPTION FROM YJORKERS' �'� BnTH 7UB CROSS 5T. \ rh 4 COMPENSATION INSURANCE SHOwER OWNEQ ,�� Lp (Thic�aclfon n��d nof b�compirf�d iF Th�work Inwir�d by 1M p�rmtt Is 1or oM Mundr�d dolton(=f 00J or less.) IaVATORY ��� � r Q AD�RESS I certify that in�he performance of the work for which this ^� permit is iasued,I sholl noi employ any person in any manner SINK � � CITY 7EL NO. +s so as to become su6jec�to the Workars'Compensation Laws. , DISHWASHER / ., a f)�1 CONTRACTOR (��O a Date � ApplicoN CLOTHES WASHER ADpRE55 �'� b � � TICE TO APPLICANT: If, after making ihis Cerlifitate of SWIMAAINGPOOIRECEPTOR � smplion, you should become subjecl to fhe Worke�s' � CITY � Compeosafion provisions of fhe Labor Code,yoo mosl forth- IAWN SPRINKLERSYSTEM with comply with such provisions or this permit shpll be STATF LIC. deemed revaked. WATER HEATER �� t�CENSE NO. CLA55 LICENSF�CONTRACTORS DECLARATION DiSTRICT NO. PROCESSED BY I hereby offirm lhat I om licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS +` (commencing wi+h Se[tion 7000}of Division 3 of ihe Busin85s OUTLETSOVER � �a`Qne_ Lt�„ and Rofessions Code,and my license is in full force and effed. 5 aeR SvSTErn FINAL d //��-/�-� VAUDATION v License Number 31.3n�;3 Lic.Class� oare � �y,.}_ �,��.�E� FINAL � Controttor?�`SC���' - e___L__��. BY � ❑ I am exempt onder Sac. a h �� B.&P.C.for�his reosan ► $ Plan theck fee �"1 .'">1.t A Date: ptUMBING PERMIT ISSUING FEE E O � • . s.c; Signature '��' TOTAL fEE � � :, , %���1 - . Plpn check appficont •. �-,,.z SINGLE FAMILY ° ��� ' �'-.�-.. . . HOME OWNER-BUILDER OECLARATION Name ��I' �;reby affirm thot I am eaempt from the Confrecfor's License �`���L� . law for Jhe following reason(Section 703I.5, Businms and Add�ess Professions Code): C��y Tel.No. ❑ I,as owner of the property,.will do�he work ond the ► srructure is not infended or offered for sole (Section 704E,Business and Professions Code). CONSTRUC710N LENDING AGENCY � � ��. I hereby affirm fhat ihere Is a mnshuction lending agenty for � ihe performanca of the wo�k far which this permit is issued � (Sec.304T,Giv.C.J. tendars q�rPPe� Lend9r+s,fidet2ar I certify that I have raod this application and state rhat the � above informotion is correct I ogree fo comply wirh oll Cooniy ordinances and Sia�e lows regulating Wumbing,and hereby awhorize represantatives of this County fo an�er upon�he a6ove-memioned propeny for inspecrion purposea. 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