HomeMy WebLinkAbout1431A (13) WONKtiKS'CONPENSA'IIONDECLAKATION ]BA6NA � qPPLICATION FOR PLUMBING PERMIT �
1 hereby uffirm that [ have �cer�ifiCate of consept to sclt ee eio(z-ea
insure,or a certiTicatz of Wbrkers'Compensa[ion Insurance,ot .
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 furnisheJ. FOR APPLICANT TO FILL W(PRWT OR TYPE) BU�LDING / Q �.' ,`��
� , A�DRESS �O ��c����.��
Cettified copy is ti]ed wilh�ht county uilding'nsp un NUMBER FIX7UAE OR ITEM • FEE �
� LOCALITY
WATER CLOSET 'C� C.4-
llat � Applicant -� � � �d NEAREST
BATH TUB CROSS ST.
E 'TIPICATE OF EXEMP710N PN WORKIRS•
COMPtiNSATfON INS[IRAh'Cli SHOWER OWNER �yt,��f
I.AVATORY qpDHESS d
(This xction need noY be compkted if the work involyed (�\
by the permit is [or one nu,�e.«t eai�s(5100)or less.) SINK - �
CITY TEL.NO. CJ
1 cer[ify ❑mt in the perfurmunce of�he�vork(or n�hich this OISHWASHER Q
permit is ix+ued,1 s�e0 not empluy any person in any mannec CONTRACTO � i ��D' O
w as to bccome subjeCt to tht ti'otkars'Cumyensation Laws. CLOTHES WASHEq U
AOORESS
Unte Applicaut c W
SWIMMING POOL AECEPTOR � �� a
NOTICI TO APPLICANT:If,a(�er making this Corti�<ate uf CITY TEL.NO. �
Esemption, you rhouid 6ecome subjeq to the W'orktrs' LAWNSPRINKLERSY3TEM ^� `/ rtt! �
Coenpensation pra��ieians of tAe Labor Cade,you must furth- yyp7ER HEATEF L C T SE NO.Z/���J ClASS ��o�y
H�ith comply n�ith such provisions or ihis permit shall be
deemedreroAed. GASSYSTEM OUTLETS DISTRICTWO. PROCE33E08Y
LICENS'EU CONTRACTORS UECLARATION OUTLETS OVEfi 1� �Q��
f hereby affirm thnt 1 am licrnsrd under pro�ieions of Chapter 5 PEft SYSTEM
9 (cummencing with Section 7000)of Division 3 of the Busi- FINAL � �O ��
nees anJ Pra(rssious Cude,and my license is in futl force and DA7E j VALIDATION
eFfect.
2/ � �� / �
License Num �/ Lic.Clnss �`�"y' FINAL �
,' �' _LI eY �C�tClcs����/
Conlracta r Dnte
� I am exempt from the liccnsing rr vir ents as 1 am a P1an check fBe
Iicensed architect ur a registnred pru n9sional en�ineet pLUMeING PERMIT ISSUING FEE$
acting in my profnfional capeci¢y (Settion 7051, Bus- �
in ss and 1`rofessions Cude).
TOTAL FEE
� Lic.or Kcg.Nu. - - ..- ..i)ate.. -.-.. ._.. .-.. -- Plan cha.:k aPPiicant - - - - . .--. .. - . .- . . . _. ._._ .
- [10��11 6�i'NER-BUIL�EN DGCLARATION Name
1 hefeby affxm [ha[ I am eaempt fiUm lht Contractor's Addms � -
License Law fia 1he fuliuwiiag reason ($ectiun 7031.5, Busi- ���y Tel.No.
ness an1 Nrofessions Code):
� � 1,xs uwnCr uF�he propztty,am cxclusivzty contracting
with licensed eontractors lo conslruct the project - - � - - � �
(Se ct ion 7044,Bus+ness and Yrofessions Code). <1�4 3�-p
CONSTRUCTION LGN�ING AGENCY �• • • • •,Fi
1 hereby aTfirm that lhem is a conslruction lending agency
for Ihe per(onnanCe of thz work for which Ihis prrmit is �.• • � Q S.Q
issued(Sec.5097,Civ.C.). -
Lendark Namc • ° • � (i 5�F�
Lender's AdJress � � O Z O 2"$2
I crrlity thai 1 havc rend Ihis aVP������un�nd stale that ihe
above informxtiun is corrzct.1 agree�o comply with al!Cuw�ty SEE RHVEKSG�OR EXPLANAiORY LANGUAGE
orAinances and State laws regulating Ylumbing, and hqreby
au[hurixe representatives uf ihi5 Counly [o en[rt upon lhe -
a6ove�minti�n property or inspnctio purposes.
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igneturc uf Yermittee e � �— �
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