HomeMy WebLinkAbout1684A WORKERS'COMPENSATIONDECIARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm.that I have a certifimte of consent to self �bq��q
, �insure,or o cerfificote of Workers'Compensation Insuranre, CE817�REV.10/81�
or o certif/ie�d—�mppy Ihereof(5��80o a .C. ,�� COUNTY OF LOS ANGELES BUIIDING AND SAFETY
P�olicy NoU r Oj�Comppny ��ry G '��, 7. �� �
Certified copy is hereby mished. �� ��
a FOR APPLICANT TO FllL M(PRINT OR TVPE) BUILDING
� Certified copy is filed w � �i p ADDRE55 !�r"1'11•�
tion depa tme � NUMeER FI%TURE OR ITEM �iy FEE �� Q n �r
r, � C� WAtER Cl0.SET }^y� ��CALITY
Date Appli4oM '✓�+ NEAREST �
CERTIFICATE OF EXEMPT19N FROM WORKER5 BAiH TUB O CRO55 Si.
COMPENSATION INSURANCE OWNER
(Thls sac�lon na�d not b�complotad if 1ho work Involv�d by SHowee
Th�permN is!or on�hundr�d dollars(5100)or I�sc.) LAVATORY � ���
A�DRESS
I certify that in ihe performance of ihe work for which ihis
permit is issued,I sholl not employ any person in ony manner SINK CI7Y �'� TEL.NO.
so as fo 6ecome subjecl to the Workers Compensation lows. pISHWASHER
QO CONTRACTOR �.
�Dote Applicant CLOTHESWASHER qpDRESS
r'^�'�TICE TO APPIfCANT. �f, ofter moking this Certificate of o 01 ,_�t-a
impfion, you should bemme subje�l to fhe Workeri SWIMMINGPOOIRECEPTOR �
�ompensation provisions of ihe Labor Code,you must forth- Cli Q
wlnc �omply '�h such prov�sions or �Ms permir shall be �AWNSPRINKLERSVSTEM STATE / uc.
CJeemed Ievoked. �WAiER HEATER {�,,.�y�� UCENSE NO, f QA55 �
LICENSE�CONTRACTORS DECLARA710N "' DISTRICT Np. PROCESSED BV
I hare6y affirm fhot I am licensed under provisions o4 Chapter 9 GAS SYSTEM � OUTLE75 //) �Q,
(commencing with Section 7000)of Division 3 of the Bosiness OUAE7SOVER <<�
� ond Professions Code,and my license is in full force and effecL 5 PER SVSTEM FINAI VALIDATION
e� p�+� /� DATE�'%.���'"'S� O,
License Number a���.7 Lic Class G 3Y1
����,�ryj�.�/ FINAL �Jj // U.
Controclor er pore__C'�YL BY vi`��'-+���-'�� �'
'� ❑ I am examp�under Sec �
B.&P.C.for lhis reason '�� ��4 p' V
Plan check fee a
Date: ! r, a o m •,rj N
� PIUMBING PERMIT ISSUING FEE$ Z
Signotura � �' ��8,,'rj Q - "
TOTAL FEE
m . � >��:�sr�
Plan check applicanf
SINGLE FAMIIY C'�..� J�E�I
HOME OWNER-BUILDER�ECIARATION Name
��^reby afFirm Ihpt I am exempt from the Contrac�or's License Address
.a for the following reason(SeUion 7031.5, Basiness ond
Professlons Code�: Ci�y Tel.No.
❑ I,as owner of the property,will do the work and the
stiucture is nol intended or offered fo�sale (Section ,
7044,6usiness and Professions Code).
� CONSTRUCTION LENDING AGENCY
I hereby affirm thot ihere is a construction lending ogency for
the parformance of ihe work Sor which rhis permit is issued
(Sec.309t,Ciw.C.).
l�neter's Fterrte
Fend�t Rtfdtrss ,
I certify that I have read this appli<o�ion and state ihot the ,
above information is correct I agree b comply with all County
� ordinonces ond State laws regula�ing Plum6ing,and herehy
�tho�ize represen�otives of lhis Counry ro eMer upon the
menr pro rty for ectio�� SEE REVERSE FOR EXPIANATORY IANGUAGE
Siynoture of Permittee pate �
. f�� '.,�.�.r�'"ra ""'
� _A!i ��*�.. �......g.�-.`�+. _ae•�
� �.��n ti . c.^Te _ �� ? 0455GNA7URE iNSPECTOR'S NOTES ��� ,V p�NtiE2 6l��LDER� � 4R,ilON
3 UNDFk I,�y 6�� � � �1-� I he•eby aff rm thal I m emp�4 m�th�C i � :'�
ROUCH LUPA[��•j.�y� j� � � Lcense Law for the iollow� g reason (SFcfon 7GJIS.
�GAS F�PIrJG _�_L J�'���,�Y �;,��• � " Business dnd Professions Code) Any c�ty or o �ty w`�:�h
'GAi 5\` T.� � �� , ,r�quires a permit to construcl,alter,Improve demofish,
- � � + -i �oF reRsir hny.s}ruct�y e, prior to�-its issua�Fce, also re�
�HO7 V kT� P.`�T 'i � � � �� ^ �� '�- � quires the o�pUfantJor sucb pefrH'if 7d 1!!e a signed stnte�
p��p p��',i i �� � ��'��' +� � ' � ° - �-� � ment fhal hc!s Ilcensed pursuant fa fhe provlvons of�ha
GAS i � � � ��' ��• �,�" � t� �'1 Conlractor's License Law(ClwpfAr 9(mmmenciny���i'h
�UTILITY Cc:.KO.:�°� I � Settion 7000)of Diuisipn 3 of tlle Business and Proies-
—__ —__ _ � �., sions CodeJ or ifiat ha is ezernpt therefrorn and the besis
' " '��°c7 � �� � ' ior Ihe allegad exompHon. Any
'�__ i__ ��_. -' violalion oi Seciion
Flh t _ f,r�lrr vn _1rors� ' -- 'n � 7031.5 by any opplicoM fo�apermH subjecls/he oppli-
cant fo a civi!penalty ef nof mo�e iFan iivc hundred
+ � douon�asoo�.:
�nD 7U Ri,- � . - � � ❑I,as owner oi the propery will do the work,and
WA � �', �Ce�. 1 ' ' � - � - ihe strudure is not intended or offered for sale. —
' .-;y 1'� ,;,�V �..�'. + ___ (Sec.70M,Buslness and Profess�ions Code: Tho Cc �
� - � �-�' � - �� tor's L�tenae Low does not apply fo an owne�ef properfy
• �;`i �- . who 6uifds or improves thareon, cnd who does such
� ' `" � work himself prov)ded lhat such improvements are not
. � ��.�. � � � (nfended or offered for sale.1!,however,ibe building ar
� ,. , �� � „ , Improvemen/!s sold wifhin one yeor of compfefion,ifie
� owner•builderwill have ihe burden ol proving that he did
. not buifd or Improva for!he purpose of sale.)
. ., . : -, ,. ;. �...
-.�,, ,...: ....... ��.
t om ezemp!under 5�. �
S.��i . .S \� t+ ,.3.1 1 . •������.� . •r
B&P.C.for this`�eason
- Dafe
Owner
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