HomeMy WebLinkAbout0784A (4) WORKERS'COMPENSATIONDECLARATION ]OA66iA APPLICATION F�R PLUMBING PERMIT �
[ Aerehy affirm that I have a certifica[e of cnnset�t to sclf ce sn(z-eo�
inaure,or a certlficate of Wurkers'Compensation Insurance,or
a c £ed copy thereof ec.38�0,L .C.
��vf� COUNTY OF LOS ANGELES BUILDING AND SAFETY
y'N4[ ompan
I � Certified copy is herebY furnished. FOR APPLICANT TO FILL IN IPRINT OR TYPE) BUILDING �
ADDRESS I
ertiPied copy is fled with Eh u ty Iding ins tlon NUMBER FIXTURE OR I7EM • FEE .
,�e t LOCALITY
WATER CLOSET I
Dete Appiican NEAREST �
BATH TUB CflOS55T.
CERTIFICA7E OF EXEMYT[ON FROM W ERS' I
WMPENSATION INSURANC SHOWER � OWNER i
(rhis section need not be completed if the wock involved LAVATORV MAIL n �
ADDRESS fC }
by the permit is for one hundxed dollazs (S100) or less.) SINK CITY TEL.NO. a
1 ceRify that in the performance ot the work for which this DISHWASHER � U �
permit is issued,1 shall not employ any persna in any manner COPIFRACTOR
so as to Become su6ject to the Workers'Compensation Laws. CLOTFtES WASHER �
ADDRESS D
Date � Applican[ SWIMMING POOL RECEPTOR ~ �
NOTICE TO APPLICANT:If,after making this Certi£�cate of CtTY � TEL.N W i
Exemption, you should becnme subject to the Workers' LAWNSPRINKLERSY TEM STATE �/� L10. N
Compensetion provisions of the Labo:Code,you must forth- WATER HEATER _ �r� LICENSE NO. �� `rV CLASS� Z �
�with eomply with such provisiona or this permit shall 6e
deemed revoked. GAS SYSTEM OUTLETS DiSTRtCT NO. PRO SSE�BY �
LICENSED CONTRACTORS DECLARATION . OUTLE7S OVER \L
I here6y affirm that 1 am licensed under provisions ot Chapter 5 PER SYSTEM i� � � �« -- �
9 (commencing with Section 7000)of�ivision 3 of the Busi- Ftwa� �� �r �
ness and l'rofessions Code,and m license is in full forcz and DATE %���' VALIDATION �
effect.
License Number��yo�Lic.Clasa FINAL.,--`��
BY �5! N��_ �
Cnntractor����_ Date ��� �
� 1 am exemP� from the licensing reyuirements as[am a Plan check fee �
licensed architect or a mgistered professional engineer �
acting in my profexsional capacity (Section 7051, Bux- PLUMBING PERMtT ISSUING FEE$ �n _
iness and Rofessions Code). TOTAL FEE
i
Lic.or Reg.No. Dste plan check applicant -
HUME OWNER-BUILUF.R DECLARATION Name .
Address
L hereby affirm that [ am exempt from the Cc�ntractor's �Q 7 Qu�l{i �
License Law for the following reasun (Section 7o3L5, Busi- Cicy Tel.No. - 4
ness and Professions Code): µ• •�• • •� .
� I,xs owcer of the property,am exclusively contracting '
with licensed contrnctors to construct the project � � ' • � G J�Q �
(Section 7044,Susiness and Professions Code). i
• • •i25G= ;
U
CONSTRUCTIUN L�;NDING AGENCY �
� L hereby affirm thet there is a constructiun lending agency � ��G 4�'FS� i
for the performance of the work for which this permit is �
issued(Sec.3097,Civ.C.). �
Lender's Name �
Lender's Address �
�
I certify that 1 have ressd this application and state that the _ �
above information is corroct.1 agree to comply with all Couniy SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances end State laws regul•rting Plumbing, and hereby
authorize � resent ivea of this ounty to enter upon the
above- iu ed �perty for i ection parpo;e�� I
- / �
Signawre ermit Date �
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