HomeMy WebLinkAbout1826A �WORKERS'COMPENSAiION DECLARATION APPLICATIQN FOR PLUMBING P
I hereby affirm thot I have a cenifimle of conseM to self �bqy��q
insure,or a certificote of Workers'Compensa�ion Insuronce, CE 8U(REV.10/81)
o�a certifpie�d ropy ihereof(5 c.3fl00,tab.C.) COUNTY OF lOS ANGELES BUILDI G AND SAFETY
P❑olicy No4�7g34�'1c���Y� 7�� Un I6c-G�'� �S�d ��a�
Certified mpy is hereby furnished.
� FOR APPIICANi T0 FIIL IN�PRINT OR TY7E) BUILDING
Cerlified copy is filed with�he county building inspeo AODRESS r'h7
tiort deparimenL NUM6ER FIXTUREOR ITEM Ca1 fEE �OCAtITV
� P "� WATERCLOSET (} �R �� �r
Date 9 ��-� AppliGoM 1 �r / �f NEAREST i
CER7IFICATE OF EXEMPTION FROM WORKERS' /� BAiH TU8 CROSS Si. /'� /
COMPENSATION WSl1RANCE SHDWER OwN[R j �
(This t�etion n�ed not 6�complN�d IF th�work Inrolv�!by MA�L
th�p�rmtt Is for ona hondnd dollon(5100)or I�as.) �qvqioev ADD�tFss
I certify that in rhe performonce of the work for which ihis
permit is issued,1 ihall not employ any person in any monner / SINN CITV v; � TEL.NO. �� �
so as to 6ecome subjecl to fhe Workers'Compensolio�Laws. / OISHWASHER �
COMRACiOR � �+yQ�. p
Date Applicanf CLOiHES WASHER ADDRE55 O � ..� �.^.
!"`��"TICE TO AP%.ICANT: If, r�ffer making thls Certificole of SWiMMING a00L kECEPTOR f
.mption, you should become subjeci to the Workers' CITY � /��`i� E /� 6�
C.ompensalion provisions of ihe Lo6or Code,yoo musi forth- LAWNSPftINKLERSY57EM Q � �J
wi�h mmply w'Ih such provisions or Ihis permN sholl be STATE � � cC�s
deemed revoked. WATER HEATER LICENSE NO.
LICENSED CONTRACTORS DECIARATION DiSTRiQ NO. PROCESSED BY
I hereby affirm�that I am licensad under provisions of Ghapter 9 GAS SYSIEM OU7LET5 �/ti
(commencing with Sec�ion 7000)of Divrsian 3 of the Business OUTLEt50v[it
V i
��. and Professians Code,ond my license is in foll force and effect. 5 PER SvSTem FINAL
/r;�,�-.0 VAIIDATION �
c DATE ,
License Num6er ����� Lic,Closs� �
Q FINAI /,+ �` O.
Contractor l ��C� . Dore "1 1/�7 BY /'��"�� �
� . O
I om exempt under Sac F-
B.&P.C.for this reason v
Plan check fee � `� �Z 6 A w��
oare: . • o � N
PLUMBING PERMIT ISSUING FEE j �f� 5 �
Signat�re "
TOTAL FEE � `� •7 a 5 0
Plan check app�iconi � ' '.. ��:�:'�o
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Nome Q 9,� %��7
'�ereby affirm that I am exempt from the Contracbr's Lican:e pddress ' ' �
.aw for�he following reason(Section 7031.5,Businesz and
Professions Code): ���y Tel.No.
❑ I,os owner of the property,witl do the work and fhe ,
siruclure is nol intended or of4ered fof sole 15ection
7044,Business ond Professiom Codel. .
CONSTRUCTION LEN�ING AG€NCY
I here6y affirm thol there is o tonslruclion landing agency for
the performonce of 7he work for which this permit is issued
(Sec.3t797.G�.C).
Lender's Name
Lender's Address
1 certlfy thot I hove reod this opplimtion and s�ote ihot the �
o6ove informo��on is rorrecL I ag�ee to comply wifh all CouMy
ordinances ond Slate laws regu7afing Plumbing,ond herehy
au�horize rapre�eNafives of this Counly 10 enter upon �he
bbove-meNioned prope�ty for inspetlion pwposes.
/������ ��// �� SEE REVERSE FOR EXPLANAiORY LANGUAGE
td
Slgnature of Permittee pote
� � ��� � , ".`i""`"".�.�b �"`` _
r�r � .� ��4 a\i.+ -
' INSPECTOR'S NOTES . � OiNNER-BUILDER D�CI.ARATION
PFR:7L'i.'.;l�^ GATE wS�''iOR' SIGNATURE _ - . , �
UN EF LAE V Rl' —�� T � � ' ',
I hereby affirm that I m . emp�fro I.�e C . i r
ROt1C4PLt,'.ti �_i/ , � - . Lcense L�w for Ihe 4 Ilo '.g .�son (S.cf 0315.
ll 8 sirtess ond Professr nc Cede):Any cify or r nty wh ch
GAS F PI'J_._ �—_'__.A_r ? _ �—_— —
Ga5 VF'�:T � � � � 1 requires a pe�m7t 10 cons}ruc�,alter,improve,demohs'�.
.--1 pr'repoir.any siru4lure, prwr to ifs lssuonce, nlso re
HOT V�n7S,^.H j �— � - , " quires fhe applicant for such permit ro file o signed srr,te-
vu�k,t�:h�e��c;r�iev<���Y '�� � - � � ' � ment that he is Ilcer,sed pursuant lo fhe provislons of fhe
GASIEST � Confracfor's!lcense Low(CFapier 9(mmmencing�•-i'h
. Sectlon 70D0J o!�ivision 3 af ffte 9uninesc ond Profes-
�uriurr:p.n;or_r�_�--- - . . sions Code)oa that fie is a�eempr thereiro.n w.d�Me besis
� • _I ____ .,�c7 � � �or Ihe alleged exempllon. Any viola�ion cf Secfion
f'��4L � � ��f�v{rr on ,imnf ' � . 703i.5 6y ony appfi[aM!or a permi�subjecfs Ihe oqoli-
• ----- tanf fo a[ivll penalty of not more�hon (ive hundred
dollars($500):
ip�Tf�.,- � ❑I,as owner of the property w�ll do�he wark,and
�w4STF aGF�^ ' • � — -� the sfructuro s nat Intonded or offered for s�le. `�
��..�.�.....,.....�.�_` ';.-_�
. , . (Ssc.7014,Business and Professions Code: 7he Cc _
� � � ' � � Yor's!lronse Low doss nof opply tn an owner of property
. ' ` wbo builds or improves fhereon, cnd who doas such
- - � � ' ' -- work himseff provided ihol such improvements ore nat
� � Intanded or o�iared lor safe.If,however,fhe hulfding or
. . .. . � � �, , � , Jmprovement Is sold within one year o!compfeiion,t6e
� owner-buildar will have f6e burden of proving ihat he did
� not butld or improve for fhe p�rrpase o!sole.)
� I am exemp'.under Sec. ,
. B&P.C.for ihis reason
Date
Owner
�_�_..�__ -,.C�TOr'S NOTES