HomeMy WebLinkAbout1431A WONKEKS'COMI'ENSATIONDECLAKATION ]BA6NA � qPPLICATION FOR PLUMBING PERMIT �
1 hereby uffirm th�t [ have �cer�ifiCate of consept to sclt ee sio(z-ea
insure,or a certificatt of Wbrkers'Compensation Insurance,or .
a certified copY thereof(Sec.3800 La .C.) COUNTY OF LOS ANGELES BUILDING AND SAfETY
wN S1-O��"1�� o.��"�
Pulicy No. Company
� Certilicd copy is here6y furnisAeJ. FOR APPLICANT TO FILL W(PRWT OR TYPE) BUILDING / Q �.' ,`��
� , A�DRESS �O ��c����•��
Cet�ified copy is filed wilh�ht county uilJing'up un NUMBER FIX7UAE OR ITEM • FEE �
� LOCALITY
WATER CLOSET 'C� 4
llat � Applicant -� � � �d NEAREST
BATH TUB CROSS ST.
E 'TIPICAT60FEXEMP7IONPR WORKIRS'
COMPtiNSATfON INSURAh'Cl�: SHOWER OriNER �yZ,��J
I.AVATORY ADDHESS d
(This xcrion need noY be completed if the work involyed (�\
by the permit is [or one Au�md dotlus(5100)oc less.) siNK -
ci7v �
TEL.NO. CJ
1 cet[ify Umt in the pe+furmauce of�he�vork(or�chich this OISHWASHER Q
permit is ix+ued,1 s�a0 not empluy any person in any mannec CONTRACTO � i ��D' O
w as to become subjeCt to tht N'orkars'Comyensation Laws. CLOTHES WASHEq F—
AOORESS U
Unte Applicaut c W
SWIMMING POOL RECEPTOR � �� a
NOTICL TO APPLICANT:If,a(ter making this Certi�<ate uf CITY TEL.NO. �
Esemption, you rhouid 6ecome subjeq to the W'orktrs' LAWNSPRINKLERSYSTEM ^� y `Q/ Z
Coenpensation pro��ieians of tAe Labor Cade,you must furth- yyp7ER HEATER L C T SE NO.Z/��G Y ClASS ��o�y
H�ith comply n�ith such provisions or ihis permit shall be
deemedreroAed. GASSYSTEM OUTLETS DISTRICTNO. PROCE33E08Y
LICENS'EU CONTRACTORS UECLARATION OUTLETS OVEfi 1� �Q�C
f hereby afFirm thnt 1 am licrnsrd under pro�ieions of Chapter 5 PER SYSTEM
9 (cummencing with Section 7000)of Division 3 of the Busi� FINAL � �O ��
nees anJ Nra(rssious Code,and my license is in futl force and Dn7E j VALIDATION
eFfect.
� � �� / �
License Num �/ Lic.Clnss �`�"y' FINAL �
,' �' _L/ eY �C�tCIc.����/
Conlracta r Dnte
� I acn exempt from the liccnsing re vir ents as 1 am a P1an check fBe
Iicensed architect ur a registnred yru nssional en�ineet pLUMeING PERMIT ISSUING FEE$
acting in my profnfional capeci¢y (Section 7051, Bus- �
in ss and Professions Cude).
TOTAL FEE
� Lic.or Kcg.Nu. -- - ..- ..i)ate.. ..-. ._.. .... .- P1an chack appiicant - - �- - . .-.. .. . .- . . . _.
- [lOk1l 61i'NER-BUIL�EN DECLAR.4TION Name
1 hereby affxm [ha[ I am exempt from lht Contractor's Addms � -
License Law fia 1he fuliuwiiag reason (Section 7031.5, Busi- ���y Tel.No.
ness an1 Nrofessions Code):
� � 1,xs uwnCr uF We propztty,am cxclusivzty contracting
with licensed contractors lo conslruct the project - - � - - � �
(Se ct ion 7044,Bus+ness and Nrofessions Code). <1�4 3�-p
CONSTRUCTION LGNUING AGENCY �• • • • •,Fi
1 hereby aTfirm that lhem is a conslruction lending agency
for Ihe perfonnanCe of tttz work for which Ihis prrmit is �.• • � Q S.Q
issued(Sec.5097,Civ.C.). -
Lendar's Namc • ° • � [15 O�
Lender's AdJress � � O Z O 2�$2
I crrlity thai I havc rend Ihis aVP������un�nd stale that ihe
above informxtiun is correct.1 agree�o comply with al!Cuw�ty 5£E RHVEHSG POR EXPLANAiORY LANGUAGE
ordinances and State laws regulating Ylumbing, and hereby
au[hurize representatives uf ihi5 Counly [o en[rr upon lhe -
a6ove�minti�n property or inspnc[io purposes.
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igneturc uf Yermittee s " �
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