HomeMy WebLinkAbout1830A WORKERS'COMPENSATION�ECIARATION APPLICATION FOR PLUMBING PE M
I he�eby affirm ihot I have a cenificate of cansent to self �yqyb�q
.insure,or a certificate of Workers'Compensotion Insorance, CE BV(REV.10!81)
or a cerrif�ie�d-��cop�y(]�h�']er�eaf(5 380�0','.�la�b..JC,.,� /� COUNTY�F LOS ANGElES BUIl�Y1�µNG. AND S FE�TY 1 -�
PQollcy No(1_(52�1=L'7_Com�y�/U/�tuh 77' �
Certified topy is`hereby fumished. ��� ��O ��
❑ FOR APPLICANT TO FILL IN(PRINT OR TVPE) BUILDING
� Certified mpy is filed wilh 1he county 6u�lding inspec- ADORESS Z r'm�
' n deparfinenl. NUMBER FIXTURE OR ITEM � FEE ��A��Ty .
—)�—� waTeR nosEr
� lrldn
Date Appli4anl �� � � NEAREST y*�,����� /
CERTIFICATE OF EXEMPTION PROM WORKERS' � Bntr+TUe CROSS ST. (/
COMPfiNSATION INSURANCE OWNER
(Thi���etlon o��d not b�eompl�t�d if fh�work lavolved by SHowER
ths prrmit I�for ona hundr�d dollon(5100)or I�u.) /� wvATOkY ��� ,
ADORESS
I cartify thot in the performance of the work 4or which this I
permit is issuad,I sholl not employ any person In any manner SINK QTY 'r� TEL O. L1�, f �
sa as to 6ecome subject to the Workers Compensation laws. � J
. OISHWASHER CONTRACTOR ; C��e r / '
D4�B Applicanf CLOiHES WASHER AODRE55 �h r
.�''OTICE TO APPLICANT: If, ofter moking this Certificala of SWIMMINGPOOLRECEPTOR
' :mpiion, you should become su6ject to tha Workers' �
�ompeneation provisions of the Lobor Code,you mast forlh- �qWN SPRINKIER SYFfM CITY�ar,d� ,,.�V� i �J
with camply wilh such provisions or this permit shall be SiqrE 1 l�C.
deemed revoked. , WATER HEAiER LKENSE NO. / CLA55 �
LICENSED CONTRAGTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm Ihat I am licensed under provisions of Chapter 9 GAS SVSTEM OUTLETS /� �
(commancing with Section 7000)of Division 3 of ihe Busineas OUTlET50VER l
and Profesaions Code,and my license Is in full force and effect. 5 PER SVSiEM FINAL
/� �,(�' DATB � /,y��j'� VALIDATION �
License Number-�( t- lic.ClossSt_.�1� ' O
Controc�or{1 f1F �W Date �� � 9Y AC l� .,,,r.y U.
O
I ❑ I om exampt undar Sec. � U
B.6P.C.for ihis reason ► a
Plan check fee �'1 8 3.0 A
Date: p�UMBING PERMIT IS5UING FEE$ �?• o o c s rj Z
Siqna�ure '�
TOTAI FEE '� � �..� .�.,7 6,5 0
. . Flan check applimnl o �: .-%i��(:�
SINGLE FAMILY
HOME OWNER-BUILDER D€CIARATION Name Q.;. 1 ���,,�
'� ereby affirm�haf I am exampt from the Contractar's ticense Address
.�W fpr ihe following ieoson(Sadion i031.5, 8usiness and �
Profesaions Code): City Tel.No.
❑ I,as owner of the proper�y,will do the work and Ihe
structure is not intended ar offered for sale(Section �
7044,Business and Professions Coda).
LONSTRUCTION LENDING AGENCY .
I heroby affirm that thmra is o construction lending agsncy for �
the pe*forrrance of the work for which ihis permit is issued
(�a.1Q4Z,Gi�.E.). .
Lendei s Nome
Lender's Address
I cenify thar I have read this applicotion and stafe thol the �
above informotion is mrrect.I agree to comply with all Counfy
ordinances ond Sta�e Iaws regula�ing Plumbing,and hereby
au�horize repre�entalives of�his Co�nty to eMer upon ihe
above-menlioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
G�S��`l�; �-�c �?-J r-��`�
Signafure of Parmiftae Da�e
- - - - _
- ---- -_. _ _ _
_�� _ _ �aw . =�-T
+Mi.��..+�+�� ��.
� _ a�r� � - •�!� arr.�. .� � ��
.i
��.=6p�dAl.r�� ,u,� i^iSRE� .'S !�NATURE INSPECTOR'S NOTES , O�PiNER-6UILDER DECI..ARAiION �
�_�_..� �--.- .. , . . , . .
UfvDEF5i.��� Jcr. "� � ' I hereby affirm that I am e empr from ihe Con,rc_iw's
x
RO�GH FLUM1 �� , I� � , ., �icense Law for the iollo�N ng reason (SFct o 031.5.
GA�F F N�: _ �� —!���/M�" " --_ . ', , _._ qeQ�epair��irurture�pr�r'al lhc�ssuanc�ls�..��h
GASV hT � 5'��_
NOT l4F T[n Y T � � u'ros the u I[an!�of Sufh ¢�T-t t0�irE 0 s C(�Si 1e�
�PLUMdu•�G FlXil�a6� � ! � �� � � �� � ment that he is ficensedpurwont to�ha provisions of�he�
GAS iE�: _��`f� r ConllaCfOr's Llcanse Law(Che�/er 9(commentin3.��iih
UTIli7Y CO.KO?IFI:i �� _`^T— Setl'ron 7000J o(Division 3 of�he Business ond Proles-
—._._____ � � � sions Codej or ihat Re is exempt tharehom and ihe bosis
__ I _ -7 I - � for fhe plleged excmption. Any viololion oi $ec�ion
�hA� ..'�� �-(��1 e _1�ronl ' • ' � . 7031.5 by any opplicant Tor a pe�mif subjects the oppli-
._._ .- � cani to a tivi!penalty of nol more�ban livo hundred
' � � , dollars(5500).:
tin�s�i.e� � .1 ' �I,as owner of the property will do iha wcrk,ond
v4 ST '+F��_; ,^ � � the shucture is not iniended or offared for sale. —
, . � (Sec.70M,9us)rress and Professions Code; The Cc .
° � . . , � � tor's Llcense Cow does rrot apply to on owner ol praperty
� � . whe 6uilde or lmproves tFrereron, ond who does such
. , �� � � work himself provided fhat such improwemertts ore not
. Infended or oliarad for iale.If,however,the bo±lding or
.� , ' . � improvement�s so7d withl�orre year of cornpletion,the
" owner-builderwilf Mave fhe borden ol proving thol he did
� ` nof build or improve for iFe purpose of sale.)
I am exemp!under�5ec. ,
B&P.C.for ihis`reason
�ate
Owner
~ i~ IfJSFcCTOR'S NOiES