HomeMy WebLinkAbout1678A WORKERS'COMPfNSATIONDECLARATION APP`,�CATION FOR PLUMBING PERMIT �
I hereby offirm that I have a cer�lficate of consent ro self �pq667q
. insure,o�a certificate of Worker5'Compansation Insurance. CEBV(REV.10/811 . �
or o ceriifled coov rhereof�5�.�800,�o_b�c.�Q ��� COUN7Y OF LOS ANGElES BUILDING AND,S/AFETY � �/
�c�;�i�� �� � �'f � �-Ol���i
P❑olicy NefLL412.T3ZCompony ' /^!'i(,Ci J�jaJ D
Ce�tified copy is he�e6y omished. gUIL�ING /
� _ FOR APPIICANT TO FILL IN(PRINT OR TYPE� qDDRE55 r���' S
Cerlified copy is filed wi � � � sP NUMBER FIXTUREOR ITEM (dj FEE
fion deparim/en�t.s . LOCALIiY r�a rv� Q r
Dale�Applicont � fA 2• 'NATERCLOSE7 � NEAREST
CERTIFICATE OF E%EMPTIQN FROM WORKER$' BATH TUB � cRoss sr. J /Y'� Y
COMPENSATION INSURANCE SHOWER OWNER
(Tbl�eection naod not b�complH�d IF fbr work invelv�d by MAIL
fhs parm8 b for ono hundred dollan(f]00)or I��c.J LAva7pRY ,2 p0 Aooeess ry�
I cenlfy thot in Ihe performonce of the work for whiCh Ihi, SINK � CIT p��� �� EL NO. 67'•�y
permit is issued,I shall nof employ pny person In pny monner
50 os fo 6emme subjed to the Workers'Compensotion Laws. DISHWASHER �
OL CONTRACTOR ( Q+I"
Date eppliconi CLOTHES WPSFfER d ADDRE55 D D� a •
���Q710E TO APPLICANT: If, afrer making this Certificote of
/"� 5 W IMMING PODL RECEPTOR �
emption, you should become subject ro the Workers' qt� �n V� 6�
,.ompensa�ion provisions of fhe Labor Code,you musl forth- �AWNSPRINKLERSVSTEM w
� wi�h comply wdh such provisions or rhis permit shall be STATE /� LIC. C.
deemefJ revOked. WATER HEATER UCENSE NO. �✓ CL�155 �'
UCENSED CONTRACTORS DECIARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am lirensed under provisions of Chapler 9 GAS SYSTEM OUTlETS �0.1 O�
(mmmenc�ng wi�h Secfion 7000)of�ivision 3 of ihe Business OUTLE150VER � i
, and Professions Code,and my license is in iull iorce ond effect. 5 PEe SYSTEM FINAL�/��/� VAIIDATION a
�j (�, DATE
Lice�se Number �+� Lic.Glass C' v 0
, Mf' t� FINAI �rjif �. � U.
Contractor � �� Date y 6Y ,�`r-.zti.rf` �
I ❑ I dm exempt under Sec. O
U
8.&P.C.for rh�s�easo� plan check fee r�1 6 7•8 A y�
Da�e: pLUMBING PERMIT ISSUING FEE 5 Q ' t, �" ° ` ° •5 Z,
Signotore � TOl'AL PEE I ���7 6,5 0
Plan check opplicant � - ,>%C.JO c=.�
SINGLE FAMILY
HOME OWNER-BUILOER DECLARATION Name
�xeby offirm�hat I om exempt trom the CoNractor's license G 9�, 5_�7
o�for Ihe fallowing reason(Section 7031.5, Business and Address �
Professions Code): City Tel.No.
❑ 1,os ownar of the property,will da tha work and�he �
siruUure is not intended or offered fof sole (Secrion
70d4,Bosiness and P�o4essions Code).
LONSTRUCTION LENDING AGENCY
I hereby nffirm thut the�e it a canstructian lending agency for
the performance of ihe work for which ihis permit is issued
(Sac.3043,Civ.C.).
ke�t7�eMs RPlen6� �
kerrlee's Addro�s �
I cen'�fy+hai I have read this applimtion and state ihot the �
above informa�ion is correu.I agree to comply with ail County
ordlnances ond Stafe laws regulaling Plumbing,and hereby
hor�e rapre3e��olives af 7his County �o enter upon the
entio r perr fa insp on pJyposas. � SEE REVERSE FOR EXPLANATORY IANGUAGE
��
ignature of➢ermi�ree Da�e .
� � .s�....�- - �..� .�..
,�., �_ _..i.� �. .�.�.., �� _.. .�s.,
___
�..���tls. '.a....V��R� �aT= iti5a CTOR'S SIGNAIURE INSf'ECTOR'S NOTES �. Q�PiIvER-BUILD�R DFCI.ARA7ICN
uND[ s�t�� � �-�'�� � � �T ' ' ,4 I hereb; ff�rm'ihot I om e.xempt f om i`,� �Co�nc�ror'a
ROJ 4 P�U' f C�- ��j' � L�cense Lnw for the 4olloviing eason �S�f n 703I.5.
G4�F P��I�, � .i}� � � Busines ond Profgssions Codc).Any ciiyo;<o�nfy wf 9ch
-��- --1 ��,� � ,,requires a perm/ttp cansiruct,alter Impro e,denol sh,
GAS V hr ,;.� ;s 1 ! - .
` I � t�r:.�oryrepai{qny sfFu«pre,pnor�t )f; is;uopec,;nfsa re-
� .. �
Hn7 N AT"! c E,� . + • � � ' qu'iras fhe bpplipnnt ior such perin�to iile'v signed a+are-
PlU EIP-'„T f � �—� -1� r'-��-��` ` � .�.-� �'� ment l6at he is ficonseL�pursuont to 1he provisions of fhe
/ / � Coniraclar"s License Law Cha fer 9 commennn� «i;h
GAS Tc`_T �f,�d(�' y, � ( P � y`
UT LITY CO ��!��,D j� Setlion 70D0J o1�iwsion 3 of the Business and Profes�
� �—-- " • sians Coda)or that Fe is exempt therelrom ard the basis
��;,.y�_ �� � � -� f o r i h e a l l e g e d e x c m p i l o n. A n y v l o l o f i o n o� S e c f i o n
i
v :-' c7 . � . -�--.�--_
�fina�, ���� r,q.j �,n .}roril '�'f' ' � �1� �•-� '� �' '-, 7Q?I.5 by any appJicvnt lor o permil subjec�s the oppli-
---- � tanf to c tW!(penalfy o1 nof more ihan live hundred
A .. r +���� ,,��'�� - , dollars(8500).:
WDU i�it, t . _ ❑I,as awner of the property will do the work,ond
/AS� c'.�ia �����ti �4 1 � '��' � � '"'�"""' ihe siruUore is not intended or offered for sale.
� �},��"� •"':- .'��, 'T (Sec.704i,Business andProfossions Code: ihe Co� ` �
- �-� tor's(Icense Law doas rtot apply}o an owner of properfy
, \;`,.-�- who 6vifds or Improves tfiereon, ond who does svch
.. . , , work himself provided Ihai such improvemenis ore nof
_ �, t � lntended or oHared tor safe.1/,however,1he bWlding or
� � ,_ - �� ... "� improvement h sold wifhin one yoar of mmpletion,the
' owner-butlder w111 have the 6urden oiproving thot he did
� �� not build or Improve{or,ythe purpose af sale.)
. , .-. .. .. .
+�'° . '�ti�n exemp!undef Sec.�.______,:�_ ,
�
B&P.C.for thi`s"roason �.
__ Dote
Owner
...y..---- If�:S cCiC7F."5 NOTES