HomeMy WebLinkAbout1649A (22) WORKERS'COMPENSATIONDECLARATION pppLICATION,FOR PLUMBING PERMIT
I hereby ofFirm that I have a certifica�e of consent fo self 20-0026�PW 6/87 �
ins�re,or o certifimte of Workers'Compensotion Insuronce, 7fiA667A
or o tertified copy thereof(Sec.3800,�ab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
POolity No. Company
Certifiad copy is hereby(omished.
�❑ FORAPPLICANTlOFILLIN(PPINTORTYPE) . BUILDING
Certified topy is filed with the coumy building Inspec- ADDRE55
tion deporiment. NUMBER FIXTURE OR ITEM @ fEE ��A�I7Y
Date qppliSanf WATERCLOSET NEARE57 1 .
, CERTIFICATE OF EXEMPTIQN FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHQ�R OWNER �,
. (Thls s�dlon n��d nm b�compl�t�d if 1h�work Involv�d by ���
fh�p�rmM Is For on�hundr�d dollon(SI00)or I�n.) tAVATORY qppRp55�
I cerfify ihol in Ihe performonce of the work for whith Ihis
' permil is issued,1 sholl no1 emplay ony person In a monner SINK CIN iEL.NO. r ,5
so as to become sub�ect to Ihe Wo s'Compen on laws. DISHWASHER
. CONTRACTOR
Date Applicont CIOTHE5WA5HER
' NOTIGE TO A7PlICANT: If, oFter mo mg th eni{icate of nDDRE55
Exemption, you should bacome s�bjecr to the Workeri SWIMMINGPOOLRECEPTOR
� Compenaalion provisione oi the(abor Code,you mUst fonh• �,qWN SPFtINKIER SYSTEM CITY TEL.NO.
with comply with such provislons or fhis permit shall 6e STATE IIC.
deemed revoked. WATER HEATER IICENSE NO. CL455
LICENSED CONTRACTORS DECIARATION DISTRICT NO, PROCESSE�BY
GAS SYSTEM Ol1TlEi5
, I heroby affirm fhat I am licenssd under proviaions of Chapter 9 �n � � r.. �
'� (commencing wifh Section 7000)o(Divi6lon 3 of the Businass OuiLEis OVER
- and Professions Gode,and my licanse is In full(orce and effect. 5 PER SYSTEM FINAL VALIDATION O
U
litense Number Lic.Class DATE �
_t
FINAI �y
ContraUor Da�e BY
j ❑ I am exempt under Sec. ¢
i
B.BP.C.far thls reasan , �
Plan check fee a
Dale: P�UMBING PERMIT ISSUING FEE E �
Signotore ~ H
TOTALFEE �.
Plan check applicant � � r
SINGIE FAMILY '
HOME OWNER-BUIIDER DECLARATION Name � ��•���?!�.C�F1
I hareby aHirm tha�I om exempt from the Controclor's licanse qddress � ii..�,�!,����.J.
' Low for the following reason(Section 7031.5, Business and
', Professions Code): City , TeI.Na �f,i 1�;��.(3
❑ I,os owner of 1he properly,will do�he work and the ���' ''`�� �
struUure is not intended or offered for sale (Section ' ���������}'� '�F
7044,Business and Professions Code). . �
� tONSTRUCTION IENDING AGENCY �� �,��.���s�E E:
I hereby affirm thof there is a canstruction lending ogenty for �
. fha performance of the work for which Ihis permif is iss�ed .
(Sec.3097.Civ.C.). �, . �
Lender's Name � .
Lender's Address .
1 cerufy that I hove reod this applimuon ond stofe thal ihe � ��
obove informotion is correci.I agree ro comply with all County �
ordinances and Staie laws reguleting Pl�mbing,and hereby
outhorize repre�entolives of this Counly fo enter upon Ihe � ,
a e-Menlioned� erty Tor inspeUion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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- SignaNre of Pe i e Date
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