HomeMy WebLinkAbout1677A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT � ��.
I hereby affirm that I have o rertificote of consenf to self 76A667A -
insure,or a certificale of Workers'Compensation Insurance, CE 81�(REV.10/81)
' o�a ce�tified copy the�eof(�c.3600�,l^,a,b�.�C,j.) COUNTY OF LOS ANGELES BUILL�ING A'N/D SA�FETrY , L�}
P�ol�cy No�Comp�ny r7lA/tC ��1� /�C'a.�r( ��Y ZJO� '-�// �
Certi4ied copy is hareby furnished.
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �
Certified copy is filed �h il ADDRE55 r f
fiondeparfinent. c NUMB[R FI%TUREORITEM C FEE ������, '�R�� �ar
Dale �/ • � Appliconf �7 �r Z. WATERClOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' �i Bt+iH iUe 2 CROSS ST. L6f
COMPENSATION INSURANCE SHOWER OWNER
(Thic s�cfion nNd nol ba complH�d if Tha work involv�d by MA��
1he permit is for one hundr�d dollon(5700)or I�ss.) tAvnroev AODREss
I certify thot in the performance of ihe wo�k for which this �
permil is issued,I shall nat employ any person in any manner SINK Op CITY y� ��_ El,NO, �7.
so as to become subject to the Workers'Compensation Laws. D15HWASHER � r
�� CONTRACTOR � QY.
Dafe Applimnf CLOTHES WASHER �
ADDRE55
�,L!OTICE TO APPLICANT: If, afier making this Cerrifimte of O Q �'
� �mplion, you should 6ecome subject to ihe Workers' SWIMMINGPOOLRECEPTOR
_�mpensation provisians of the Lobor Code,you must forth- ��T /� rJ"�,1✓� ��
wi�h com I with such ravisions or �his armi� sholl be U+WNSPRINKLERSYSTFM
P Y P P STATE /�v LIC. /1
deemed revoked. I WATER HEATER � UCENSE NO. � C,,,,7 Lf CLA55 L+
IICENSED CONTRACTORS DECLARATION � DISTRIQ NO. PROCESSED BY
1 heraby offirm fhat I am licensnd under provisions of Chopter 9 GAS SYSTEM OUTLETS
(mmmencing with Section 7000)of Division 3 of 1he Business OUTlET50VER p�
and Professions Code,and my license is in fufl force and effect. 5 PER SYSTEM fINAL VALIDATION
License Numher___J.ZL�4s2—Lia Class C 3b DATE G/�'�/4� U.
{���(� �(� FINAL
Contractor � h�r � Date J�J . BY ���,.,+'�'
�
I � O
I om exempt under Set. �
B.&P.C.for th�s reason plan check fee .`'1 6 7,7 A W
a
Date: p�UM81NG PERMIT ISSUING FEE$ Q t' @ � � � �5 Z
Signmure ��
TOTAL FEE ,� � ° '7�5�
Plpn che[k applimnt � �� � 7 0.:(1.�
SINGIE FAMIIY
HOME OWNER-BUILDER DECLARATION Name O g,� J�H�J
'r��reby offirm tho�I om exempl from the Contracfor's License
�for the following re�son ($eclion 7031.5, 8osiness ond Address
Frofessions Code): Ci1y Tel.No.
❑ I,os owner of the properfy,will do rhe work and the -
structure is nol imended or offered for sale (Sedion �
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm ihot Ihere is a conslructian lending agency for
ihe performance of the work for which this permi�is issued
(Sec.30R7,Civ.C.}. '
lendcr's IVame
lerxfer's�Addt�ss
I certify thot I hove read this applimlion ond state thot the .
� above informo�ion is correct.I agree ro comply with all Coumy
ordinances and Stote laws reguloting P�umbing,ond hereby
Whonze reprosenlotives of this Coumy to en�er upon the
bo -me ti � rt ,for n eUic�p^���rposes�
/ e'1/0 SEE REVERSE FOR EXPLANATpRY LANGUAGE
�i� �f�
Signoture of Permittee Date
�- � � y�
.�.e+►..-�.w..�ar�.�
� � ��. �s +r��r a�. a� �i�x f��
v [ � enre i^�ST�eciq¢SSiGNAT�Re WSPECTOR'SNOTES � ��._ O��ilyE?BUILDCR,pECIARATION �
J��E_..�i��t,.. ���-1 Q, '�.� . � y�-.: ,. , here6y aPf rm��hat I am exempt�from tne Ccntrccre�`.
ROJ H PLUf.t f . � License law for the folloW ng reason (5�f 03I.5.
.qt p p,� , -� � . . ��Busirtess ond Profess�on:Codep Any afy or o� ry. �ch
('A VEfI? ' ��y t• 4�z , �re uires a permli fa consfruci,o!t� ,impro e d mo�"s`i,
- },1�FOr�apair t{nysjructp�e prror tp1?� y�ia�c� �alsa re-
HOT 14'ATFk F 1 f;_, ,f �i� t�. - . � `� �"qurras+he op�iicbnf�Or such perrrf��"to�le b s��ned cr�re-
"PLLLM5i:6"rT: R._-��-�� �=-v'3—S�.r ..♦ � . � .
� ;_ meni tBol he is ficensed pursuon•fo the provisions of fhe
Ga5 TEST � Contraclor's Llcense Law(Chopeer 9(commenciny��-i±h
UTIL�7v c0.V i I D J�I��I Sectlon 7000J o/Division 3 0/the Buslness and Profes-
— sions Coda)or tha�he s ezempt therefrcm and ihe basi5
� i�� � '� � "�" /or �he alleged excmption. Flny vrola�ion oi Secfion
Fm:at - ' ���'�'.l'f:r nn�ruref� ' ' . . - . , � ����---_- 7031.5 by any appficaM for a permit subjects fhe oppfi-
—��--- - mnt ta a civif penalty af not more fhan/ive hundred
—?--' �. � . ,
, .. �y ;_t . .. :�-,.. .' �...�.- ... �, dollars(3500).:
ti�UST ' ^ �� t ❑i,as owner of ihe properiy wiil do the wor�c,cand
�W\5 C v"2J � :;'� �\ ^.(� `�� � '� —"---- ~ Ihe sirudure is not in!ended or oPfe�ed for saie
��r � '� t � (Sec.70M,Buslness ondProfessions Code: iheCc'� �
,..,� i!.... '.\ ... . .. .� ... .. - ---
. - .._ tor's Llconse Law doss not appfy fo cn awner of prop_;ly
' ' who bui(ds or Improves thereon, and who doos such
�- �� ��' �� " '' � �� �-� -- .,,, � j work himself proWded lhat such impravements are not
1n�endedorof(erad£orsale.l(,howaver,ihebuildingor
� . � � � . �- .. � 0 Jmprovemani is sold within one yeor of comple�ion, the
� ' owner-bWlder will hove�he burden aI proNng thai he did
- not buifd or Improve Ior the p�rpose of sale.)
. �-. ��.-i .`+���.,, �,"..
� - Ic� xemp`under ,
'.� .'1".�_ ,.�.l�� � ., _
� B&P.C.for this�'reason
Dote
_ a'�
Owner
--.--_._____�.1_cryEC70F�'S NOTeS