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HomeMy WebLinkAbout1316A � WORKERS'COMPENSATION DECIARATION ppp��CATION FOR PLUMBING PERMIT � i hereby,afflrm fhot I have o certifica�e of consent to self 78A867A insure,or a certificote of Wo�keri Compensation Insoronce, CE$17(REV.8/86) o�a�en�fied copy iheroof�,�gJc.380e0,Lob.C) � COUNTY OF LOS ANGELES DEPT. dF.PUBUC WORKS Policy No.�.�mpany U���_�V n r�s f . � . . ❑ �_f� Ceitified copy is here6y furnished. •^ FOR APPLICANT TO Fltl IN(PRINT OR TVPE) BUIl61NG !'� �h�I CeniSied Copy is filed wifh!he county b�iiding inspet- ADDRESS u {�,� �p 1`" " tion daportment. NUMBER FlXTURE OR ITEM � iEE ny�1�_;� �c�cnurv � Date t-1.-R`7 Applican� ����1<�'�`-+x� WAtERCLOSET Q� NEAREST CERTIFICATE Of E�EMPTION FROM WORKERS' �� BATH TUB ' O ru^� CRO55 ST. \ � � COMPENSATION INSURANCE O' v�J $HOWER OWNER ,� (TAi�eutro�n��d rro1 b�complN�d li 1h�work Involred by ��� fh�p�rmk Is for om Iwndr�d dollan(S1D0)or I�ss.) tqVqiORv � i �� qooRESS I certify Ihot in ihe performance of the work fw which ihis permit is issued,I shall no�employ any person in any monner � SINK �� CITV J;n TEL NO.Q6 95 . so as to become subject to ihe Workers'Compensation laws. . � " DISHWASHER �� CONTRACTOR � � � q,-f?ate applicani CLOTHES WASHER �� A��RE55 . TICE TO APPLICANT: If, ofter making this Certificate of ��b� � �t�l " _mption, you should became su6ject to Ihe Workers' SWIMMINGPOOLRECEPTOR p Campensation provisions of ihe Labor Code,you mwt forth- ��T� �o lp TEL.NO.��� wi7h com I w�lh such lAWNSPRINKLERSVSfEM p y p�ovisions or fhis permit shall be S7qTE IIC, � deemed re�oked. WATER HEATER � Ob LICENSE N � CL0.SS LICENSED CONTRACTORS DECLARA710N p15TRICT NO. PROCESSED 8Y I hereby offirm thot t am licansed under provisions of Chapler 9 GAS SYSTEM OUTLETS (mmmencing wi�h Section 70D0)of Division 3 of the Business pUTlET50VER 0. Q�� and 7rofessions Code,and my license is in full force ond effect. 5 7ee SvsTEM VALIDATION CY License Number �-�`��C3�1 �ic.Class� DA�L //�� �� V FIPlAL � Contracror � � �- te� BY s�y,,,�l� � D a I am exempt under Sec. 8.8P.C.for fhis reason ����-� �'���� � Plan check fee � oare: � ; . « . m� PIUMBiNG PERMIT ISSUING FEE$ � SignaNra � � e- p�G'��,v Q � TOTAL FEE 5O _ Plan check oppficant .. .� L`� '�'�,. ::i%�. SINGLE FAMiLY �, � � HOME OWNER-BUILDER DECLARATION Name � � •��`P� raby offirm thot l om exempt from the Contrador a Licanse Address � � _ Law for the following reosan�Sedion 7031.3, Business and Professions Code): � � Ciy Tel.No. � ❑ 1,as owner of ihe property,will do the work and the . structure is not Intended or offerad for sale (Sedion ► 7044,Business and Proiessions Code). CONSTRUCTION LENDING AGENCY I hareby offirm thor ihere is a conshuction lending agenry for . �. the perfo�mance af the work for which this permit is issuad (Set.�47,Eiv.C.). taFid'Sr i 10�6 � Lender's ISNNPess I certify thot I have read this applico�ion ond sfare�hat�he . . above information is correcr.I agrae to comply with oll Gounty ordinances ond State laws regulating Plumbing.ond hereby authorize raprasentotives of this Coumy�o enter upon the above-men�ioned property for inspection purposes. 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