HomeMy WebLinkAbout1431A (15) ! - _______ _.
�'ORKERS'CO!�iPENSATIONDECLARATION �eecsvn �
I hereFy effirm Ihat 1 have a ttrtificate of conse7rt [0 5��< <E.,>(a-ee) A P P L IG A T 1 O N FO R P LU M B I N G PE R M IT
� insure,or a artificate o}W�rkers'Compensation Inmrance,or �
a certiCied copy thereoC(Sec.7600 La .C.) � COUNTV OF LOS ANGELES BUILDiNG AND SAPETY
r����y Nv�N g�-o�g P',1�'�1
� Certified copy is hereby fumished. FOR ApPLICANT TO FILL W(PRINT OR TYPE) BUILDING .// � � . d � �
.,_,t A�DRESS ✓�O �j��`.�—��
'pCl Certi(ied coPY�s fl�ed with[he coun[r building' spr 'on NUMHER FIXTUflE OR ITEM � FEE �
�� � �y�' WATER CLOSET Oa LOCALITY �
Dat � Applicant � NEAREST
BATH TUB CROSS ST. �
'E TIG(CATG;OF 1iXE51PT[ON GR f WORKERS' ���_J
COS1PfNSAT10N[hSURANCE SHOWER OWNER �
MAIL
(This sectiort need not be completed if the work involveJ Lavn70aY C'� qODRESS a
by the permit is�for one hundred doUus(5100) or less.) SINK �
CITY TEL.NO. U
t certify that in the performance of ihe�vork for which this DISHWASHER � �
permit is issuad,[shait not employ any person in any manner CONTRACTO �(Q• � '
so is[o become suhject to the K'nrkets'Compensqtion Laws. CLOTHES WASHER ADORESS U �
Dafe Applicant � ��� W �
SWIMMING POOL RECEPTOR .
N071CL TO APPLICrWT:If,afmr making this Certilicate nf CITY �. TEL.NO. �3 t�i7
tizemption, }rou should become su6ject ta the Wnrkers' LAWN SPRINKLER SVSTEM '7 ¢/� �/ Z
Compensation provisiom of Ihe Labor Code,you must inrth- WATER HEATER LIC T SE NO.Z l��P 7 CLASS ��=�5�
with comply �eith such provisions nr thie permit xhsll be
deen70d revokeJ. DISTRICT NO. PROCESSED BY
GAS SYSTEM OUTLETS
LICENSEOCONTRACTORSDFCLARATION OU7�ET5OVEN � � �Q9. _
I hcrehy affum that I am licensed under provisions nf Chapter 5 PEFl SYSTEM -
9(rnmmencing rvifh Section 7000j nf Di�'ision 3 nf the B�isi� FINAL ?
ness and I'rofessions Code,ond mY licrnse is in full force and onTE ✓ �q �� VALIDATION
eflect. / f
License Num ��� ` Lic.Class /� �� By AL���(,y/
y � � ,y��r
Con�ractnr � ` Dafe
� i am exempl from the IicenFing re uir ents as]am a P�an cheek fee
licenseil archetec! or a teglatered pro essional engineer PLUMBING PERMIT tSSU1NG FEE S S(`� � �
acting in my professional c�pacity (Sectlon 7051, Bus• � � �
iness and ITnfessions Code).
70TAL FEE
Lic.or Re6•h�- Date Plan check epplicant
H091C 04�'NFiR-BUILDER DECLAR.4TION Neme
I hereby atfirm that I am exempt from the Contractor's Adarecs
Littnse I.aw for the tolMwing rrason (Section 7D31.5,Bvsi• City Tal.No.
ness and Frofessione Code): �
� f,as m�rer of the property,am ezciusively torttnctirtg . ,
�ith Iicensed contractors m constmd the project .
(Seclion 7034.Ausinrss and Professions Code). �� u'.z� A
CONSTRUC710YLENDING.aGCNCY #:� �'• • •5 �,
i herefiy afFlrm that there is a construclion lending agency r:• • ,� �5.Q
for ihe perfnrmance of the .vork for ahich this permit is � � �� . ,.
.. .._._.. ... .
issued(Sec.3097.Civ.C.). ... .• • • ' (z 5 O� . .
Lender':Nome
Lender's pddress � � O 2 O Z`8 2
[certify that 1 h�ve read this appiication and state that thr
above intormation�s correct.I agree to comD�Y���th all Counry StiF RT:VERSE FOR FXPLANATORY LANGUAGG
ordinunces and St�te Iaws regulnting Piumbing, ond hereby -
aufhnrize reDresentatives of this County to enter upon the
obove-rpFnU n propttty or inspectio purposes. � '
/ (
ignature o(Permittee a ` �
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