HomeMy WebLinkAbout1672A WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMlT �
I hereby affirm that I have o cerrificate of consent to self 76A657A
insure,or p certificafe of Wprkers'Compensofion Ins�rance, CE 817(RfV.IOBI)
' or a cerrfied copy ihereof jS'e''c).3800,Lob.C.) COUNTY OF l05 ANGELES BUILDING AND SAFETY y
P�olicy N��_C6mAany 5�'a�"e ���' ��.�r�."�-S� /'� �rv-�
Certified topy is here6y urnished. BUILDING vy
� FOR APPLICANi TO FILL IN(PRWT OR TYPE) qDDRESS �I^�YJ/�!V
Certified mpy is filed wi Ih aunt
�iondepar�ment. NUMBER FIXTUREORITEM � FEE �OCAUTY
' WATER CLOSET a r
Date �g ty�App 4an1� � f NEAREST
CERTIFICATE OF EXEMPT19N fROM WORKERS' �J,r. BATH TUB ,^�� CROSS Si. I� I
COMPENSATION INSURANCE SHOWER OWNER h�
(This s�dton nNd no�b.compl�fed i11M work Involv�d by MAi�
ihs pmrmit is Fnr ona hundr�d dollan(5700)or leu.) � LAVAiORY � Q� qppRESS
1 cerlify 1ho1 in Ihe performonce of 1he work for whith this
permi�is issuad,I shall nol employ any person in ony monner SWK CITYGO v{ �Q� EL.NO. � �
so 05 l0 6ecame so6jecl fo ihe Worker5'Compensotion lows. ' DISHWASHER
CONTRACTOR � h�7Yr
�- bate Applicant CIOTNESWASHER D /� ��
��OTICE TO APPUCANT: If, after making this Car�ifiwre of ADDRE55 r�
� tmption, you should become 5u6jecl fo 1he Workers' SWIMMINGPOOIRECEPTOR
_�mpensption provisions of ihe Labor Code,you mu5�forth- LqWN SPRINKLER SVSTFM OTY �.
with comply wilh suth provisiOns or fhis parmit shall be STATE Cy IIC. ^
deemed revoked. / WATER HEATER IICENSE NO. p CIASS ��
LICENSEb CONTRACTORS DECLARATION DISTRICT NO. 7ROCFSSED BY
� I heraby affirm thof 1 am licensed under provisions of Chapier 9 GAS SYSTEM OUTLE75 � 1 O�� .
(commancing wifh Seciian 7000)of Division 3 of the Business OUT�Ei50VFR �'
and Professions Code,o�d my license is in full force and effxt. 5 PER SvSieM FINAL � �nuoanaN y�
p /� �/� DATE �! (�/�•� p.�
I License Number ���e 3 Lic.Closs�l� O
FINAL � U
Conrratlor�'� � Date q-tU 4 BY ���� �
I ❑ I am exempt undei Sec �
B.BP.C.for ihis reason -�� 6 7.2 A
Plan check fee , a
�p1e� PLUMBING PERMIT ISSUING fEE S Q " � � � F �5 Z
� Signot�re �
TOTAL FEE � � ` e��'.S O
Plon check opplitom • < < '/t.�J Q�
SINGLE FAMILY
HOME OWNER-BWLDER DECIARATION Name 0 9,1 5�8 7
,'���reby affirm rha�I am exempi from�he Contracror's License Address
.v for�he following reason(Sec�ion 7031.5, Businass and
Professions Code): �i�y Tel.No.
❑ I,as owner of the property,will do the work and the
structure is not intended or offered for sale (Section ,
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I he�eby affirm thot�here is a construttion lending agency for
ihe performante of�he work for which ihis permit is issuad
(Sec.3097,Civ.C.).
Lerd�s Name�-
lm�dei s AttdtTYs- .
�certify thot I have reod Ihis opplication ond srme ihot the ,
above informa�ion is mrrecr.I ogree to mmply with all County
or �nonces ond S�aie laws reguloHng Plumbing,ond hereby
au oriz repra3 ntarives of this County to enter upon fhe
a e- nfion � �e��y ar sp pu ses
�1 l Y�7 SfE REVERSE FOR EXPLANATORY IANGUAGE
Signoture of erminee Date
�nF�.��O��,�,� , �� c.,Te w5�€CiOa'SSiGn7.§TURE iNSPECTOR'SNOTES ONiNER-6UILD[R DFCI.ARATICN �
. _-_..� ..._ _. �_ .,. . .. � . . ..... ' 4.. ;� '.a
-^--�-�_. �. , . . _. e-�
UNDE2�.At:1�_���_� .� �� ;„ .°.� �� I hereb affirm'ihat I am .. � : ����...:
� y exertipf�rom Ina C t. ior's
ROJGH VLU^J I � ' '� � ��, L<ense Lrnv for �Fe tollo•Nmg enson (Sa<}0 7071.5,
„AS P Fitar, �.�:.��---�'-: ��'' — -- - �� nusin�ss and Pro(essiom.Code�; Any c�ty or.o miy.<},'.h
as VEiJ'_ ' _� _—_—_�__—... requires a qermlt to cons�ru,-t.after Impro e d 'oLsi.
` ' � �dr r�pav any structure prior ta ifs�iss�jence a so re
HOT 4�AiE�i- TJtv � :. 1 � � ��quiro3flie cppllconYfor such perrvt'I fo fR'e 6 si�ned s�r,!e-
FLUP4,;�.�3 r'�i �i�t -~ 4�� �� '" ' ' a � � '"- ment iha�he is licensed pursuant ro N�e provlsicns o!the
i ...
._.—...—_��___ -- � _ • . ..
GASTES' � -fr ; p 1 Conlrnctor's Ucensv Law(Chapter 9(commnnci»y�•�i!h
UTi�iTY�O u���F��_ --- Sacfion 7p00)of Division 3 o/the 8usiness and Profes-
— -- � sions Code)or thal 6e rs exempf�herefrom cnd�he basis
y__ _� . _ ��" '� ���� /or hhe alleged ezcnpHon. Any vlolaM1on oi Serfron
F��A� �.�= �.���_ f�o r ��ront '" - ' ' ' ���� � � 7031,5 by any applicanf tor a parmi�sub�ects Ihe appli-
- ' 1 cant fo n crvi(penalfy of not more Ihan 1rve hund:ed
q '-���' . ��-�- dolfars(5500).:
rfINDUST��.l.t � � -. ❑I,as owner o`+he property�•iill do the work and �
!wA 7E -�-z0 �'�t��V���, "+� the structure is not intended or offered for sale.
.. �_. .T�,' � . .'�.
M,\ ��..`1 �� `.� ... ._ •i�;'. � . ��^- � tofs Lkense Low does not apply fos noowner of p op.,ty
„'T• , � who bui(da or tmproves thereon, and who does such
�• - ��-•����- , ., . , work himseff provided tfiaf sucb improvements ore nol
inlended or offared for safe.ff,however,the bullding or
� _ — �•� — � � �a �mpravemen!is sotd wiihin one ycor o/compfetion,/Fe
� � owrrer-builderwtll have fhe burden of proving that he did
"�� not 6ui1d or improve ior fhe purpose oi sole.f
',4 am eaeemp!undenSec. ,
� • i' i�� :�i�! ' , ....,_ � .
B 8 P.C.for this`reason
Date
,_ .. _a'`t
Owner
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