HomeMy WebLinkAbout1194A (5) WORKERS'COMPENSATION DECLARATION � ���wu�w
I hereby aflirm ,he� I have e��.�,r,�.,e of consent to self ��.���.-.e, APPLICATION FOR PLUMBING PERMIT �
insure,or a certiPcete o(Workers'Compenastion Insurance,or . .
a certified copy thereof(Sec.3600,Lab.C.) �3 9OZ COUNTY OF LOS ANGE lES BUILDIN(3 ANO SAFETY
Policy No.2.Ql.S.�.6Compeny $�SCIE . �
� Certified copy is hereby furnished. FOR APPIICANT TO FILL IN(PFINT OR 7VPE) BUILDINO
ADDHESS /}� ama 'tas DY.
� Certi4ied copy b filed with the coun[y buildin4 inapnction NUMBER FtX7uHE OH ITEM � FEE
�e,��j��{.� LOCALITV .
D.te ` � !�Applicant G@I12r5I. Installati Ll WATER CLOSET '�'
N AR T ��.��
BATHTUB � CROSSST. Sa�B�'1�7d
CERTIFICA'fE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE SHOWER OWNER '8t@r ,
LAVATORY MAIL .
�(This section need not be completed il the woek invoNed ADDAeSS saae � a
by the petmit is Prn one hundred do�aze (5100)or lesa.) SINK CITV � TEL.NO, SC�B—f33 c�j
1 certity the[in the performance of ihe work for which this DISHWASHER �
permit is iuued,[shall not empioy any persort inany manner CONTRACTOR General Inatallation �
so as to become subject to the Worker%Compensation Laws. CLO7HE3 WASHER AOORESS 6558 West BLVC3. W
Date Applicant SWIMMING POOL RECEPTOR � a
NOTICE TO APYLICANT:lf,atYer making this Certifcate of CITY LOS Aageles TEL.NO.�IS�—I54 N
Exemption, you should become subjec[ to the Workers' LAWNSPHINKLERSVSTEM � gTATE LI0. z
Compensation provisions of the Labor Code,you must forth- yyq7ER HEATER LICENSE NO 1S1a39 �� S C36
with comply with such provisions or this permit shali be
deemed tevoked. GAS 3Y37EM OUTLETS DISTRICT NO. PR ESSED 8Y
LICENSED CONTRACTORS DECLARATION OVTLETS OVER � �
t bereby affirm that 1 am licensed under provisionsbf Chepter 5 PEH SYSTEM
9 (commmcing with Sectfon 7000)o(Division 3 of the Busi• - F�µAL � VAIIDATION
nesa and Profnsions Code,and my license is in full force and DATE
effect.
fINAL
License Number 151839 Lia Class C36 Bv ��/,����f,.i .
I ContractorW_Pr�fVlli nate 4/5/55 ' _
'�7,� �
I¢m exempt trom the licensing requirements as i am a � Plan check fee
'� � licenaed archiiect or s te¢istered professional enQineer �� � '�t �� ` c
actinQ In my proYessionst capacity(Section 7051, Bus• PLUMBING PERMIT ISSUING FEE S 8 rjQ , ��f�,,,,I ��Q
��`D ..
i� ineas and Profeaions Code). TOTAL FEE 12 5� , .. : � _
J C y
i Lic.or Re No. Date Plen ch�ek applicent
i;
a• t?3C°-�"1
" HOME OWNER•BUILDER DECLARATION Nem�
if
'�,� 1 hereby efP'vm that I am exempt hom the Contractor's Addrms
�;� License Law for the following reason (Section.703L5,Husi- Cky Tal,No. .
!�� ness and Professions Code):
.(� I,es owner of the proDerly,am eaclusivNy contracHng
� with licensed contqetors to construct the- project . .
' (Section 7044,Bu+ineae and Profrasions Code), � . , � ,
! CON9TRllCTION LENDING AGENCY
:� I hereby affirm that there ia a construction lendin¢a¢ency , �� � 9,U A
�, (or the performance oC the work for which this permit is � .
� �saued(Sec.3097,Civ.C.). �.� ��� • �5
. Lender's Name � � '
����Lender's Address : .�.• •�� 2 5�
��)I certi(y that i have read this appiication and state thet the � � • • � � 2 5��
above information is correcL I agree to comply with all County , SEE REVERSE FOR EXPLANATORY LANGUAGE � O L O 4�8 2
'�ordinmces and State laws regulatin� Plumbine, and hareby �
'� authoriae representetives of this County to en[er upon the
`. abovo-menNoned property for inapection purposes. �
9 . f ��,.� /e?�/_�/
� Signature of Ysrmittee Dete � , �
� iNSPecroa�s NorEs 015'NER-BUILACR DECLAP.ATION .
APPROVALS DA7E��"..,ly�.?'�CiOR591GNATURC� � �
UN�EFSLAC�IVORK ��� -� � , "� � � � '
FlOUGH PLU�iGING I hereby affi�m Iha[I am excmpt from the ConUactor's
Licensr�I.a�v for�tl�c foliowing reason/Sec�iorr 7031.5.
Gas PiPiNc �- � � - �� � ���� �� � � � - � �� �" ' Ilusrness and Projersior.s.Code): �tny riry ar county
- �aSVENr - - . � .�. . '--. _ ". x�hirh requires a pen�rit to cortstruct, a!ter, improve,
Ho'r v1a'rert ra[nTeR� �� � denrollsk,or repair miy,rtmc�ure,prior to its i.c.cuance,
. . �--(-----.— � .. .a1s0 requirrs �lre applican� J'ar suck permii to jile a
� ^1 Meirdc FixruRES. . . . �.�. �. �.'- � . . . . , � --- - sr;rted�s�atemerit �i+at��Jrr is�licensed urruent !o the
.: .-' P
��5-E57 � �-����'��'-.� . . � �� provirionr af flre Coi�tractor's I.rcer�se I.aw ICltapter 9
�TiLi7V co.�NOnFieo � � (conrmen;rng widr Secfioir 7000) of Dirisrun 3 of tlre
.._., � r:-... .
.__.. . . . � . � ' - llurinesr and Professiar�s'CodeJ or deat !re is exentpl
� � Uierefrom aud thc hasia for the alleged exernptiat.Arty
����AL - �ist�e,2� Ra �40r,.t���` � . � . . -- - � -- � � vrola�ion of Secriori 9031.5 6l'any apPlicurit fora peritii�
. - , �� _ � � nibjeclr tLc applica��i to a ci�d!penalty of rmt nrore tha�t
iNL7U:7FtI�L.'"`—'---- _ . �. �. •- . . . firel�tu�dreddollars/SS00J.:
r.�ns're nFFr.ovF� � � -" -� � -' � � � ❑[.as o�ener of Ihc property�aill So lhc worA,and
._. ,..,� - �� . � the structure is not intended or offered for sale. .. .
_.. � `� • '� � � -� '� /Sec. 7034, Business and Projrssiau Code: The Co�r
'- . ,- .. , � _,_ _- , � � , . , _ '. ' _-_ � - _' . . . . . tractor's Liccnsc Lax�do.s not apply�-ro crr oivner oj
- � �- � �- � property.�rf�o Ltrilds or iir�prover thereorr,mtA�i•/io docs
:�i � . -�.��.r,_ ; � � - . . . . .,�� tucli irork lrin:self pronided that tiecl� Lnpros•ements
� � -� � �� � � - � � � - are not Lrtei�ded or ojJered jor sale. If, kowerer, tlie
� ' � . , � � � '� . , -. �, building or rrnpro��emen� ir so1J wirfri�r.o�te year oj
. ' � ���� ' complerian, 1Le owr.er-builder wiH hm�e d:e burJe�r
�. - -�._'_ ' - . .. . . �. . ' ., � oI prorrng thn7 Ge did nat build or rntprore for d�c
. .. . . . . .- . _. purpnreojsale.) - . . �
�' - I am exempt m�dcr Sec. ,
C R'P.C.(or this rcason ' �
. , _ , cv,- . .
. . , J _ . _ Date
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� INSPECTOR'S NOTCS � . � � • .,
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