HomeMy WebLinkAbout1347A (7)OI SAPIONDECLARATION
'°"°•'" APPLICATION FOR
PLUMBING
have
I hereby affirm that I have a' certificate of consent to self
c¢ slr (z -e.)
PERMIT
insure, or a certificate of Workers' Compensation Insurance, or
a certifiad copy thereof (Sae. 3600, Lab. C.)
(s� �,��, ����st j�,
...Policy n..
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
No.36-16Company t't'►"1 _
0 Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING f
Certified copy is filed with the county building inspection
NUMBER FIXTURE OR ITEM • FEE
ADDRESS
dep tme j
99ff ��, j ;
WATER CLOSET
LOCALITY
'T!
Date�,T� Applicant 1� -•)�
NEAREST
BATH TUB
CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
SHOWER
OWNER ��
(This section need not be completed if the work involved
LAVATORY
AIL
AD DRESq_,77 �W#2
by the permit is for one hundred dollars ($100) Or less.)
"-
SINK
CITY '�
T L. NO.
I certify that in the performance of the work for which this
DISHWASHER
,63
permit is issued, 1 shall not employ any person in any manner
CONTRACTOR le. n.3c
sn as tob eecommee subject to the Workers' Compensation Laws.
CLOTHES WASHER
ADDRESS01
Datsll.��yL & Applicant
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If, after making this Certificate of
CITY j
TEL. NO.
Exemption, you should become subject to the Workers'
LAWN SPR IN K LE R SYSTEM
STATE
LIC.
Compensation provisions of the Labor Cade, you must forth-
Wg7ER HEATER
LICENSE NO.
CLASS
with comply with such provisions or this permit shall be
deemed revoked.
GAS SYSTEM OUTLETS
DISTRICT
,
PgOCESSEC
LICENSED CONTRACTORS DECLARATION
OUTLETS OVER
/
I hereby affirm that I am licensed under provisions of Chapter
5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi-
O
FINAL
/`
�/Ae/IDAT
ness and Professions Code, and my license is in full force and
C' DATE
effect.
�r� �`c3
FINAL
License NumberaS—& D— Lic. Class Lt.1
eV
Contractor R �_ __ Date 1-2 6--t2t
I am exempt from the licensing requirements as I am a Plan Check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE $
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lic. or Reg. No, Date Plan check applicant
HOME OWNER -BUILDER DECLARATION Nem.
I hereby affirm that i am exempt from the Contractor's Address
License Law for the following reason (Section 7031.5, Susi- City Tel. No.
ness and Professions Code);
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sae. 3097, Civ. C.).
f.anOdn's.
Lamdep'.
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mention/d property for' ction purposes.
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