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Home My WebLink About0695A WORKERS`COMPEN9AT10NDECLARATION �- vuuvw� AP�i..��.T1O��FVR P�:�.�B.I�-7J� PER��T. �11�� I here6y atNrm tMt I dsvq r ceetMicate of cona�nt to seif es•n Is-rol • � inaure,or a�ceidCicafa ot Workeh'Compemetion Imurance;or_ �. � � . - � . -� . � � �'J � a certified cppy theteof(Sec.3800,Leb.C.) f . ��,yy�' �� COUNTYOFLOSANGELEB SUtLD1NGANOSAFETY Policy No�S�6ompw . . . . . . . . . �� Q Certified copy b,Aereby futnithed�. �- - FOH APP�ICANT TO'FILL tN(9RINT OR TYP£). -` �SUfd.:OFNB � �// � A�6RE83 � C..E.. �' rtttfed copy��filed wlth cbunty llding tnapection NUINBER FIXTUqE OR ITEM ��,. . F.EE � attmen4 � WATER CLOSET �OC.AILITY Dste��,��.r�Applicaat � � Nfl . . � . . � �� BATM TUB �CROSS ST. CERTIF[CATE OF�EXfiIitPTION�FROM WORKERS' � � �COMPENSATIONINSURANCE SHOWER � � � OWNER �LAVATORV MAII , (Thl! lECtlOrt IIE04/10t be 1EtOd�[f1M WOfk ilrvolved . . ADDHESS. . by tfie peimit ia'tot one h�,doll�n (S100)ot lets.) S�NK � . CITY �TEL� O I cedity that in the performence ot tha work for which t6is permit is iisued;I shall�not�mploy any�perton in anY mannet D�SHWASHER COhTRACTO V so aa to become mbJect ro Me Work�re'Compeneatioa Laws. Cl,O7HE8 WA9HER � ADDflESS ' O � Date �Ap��icent� - � SWIMMING POOL RECEPTOH MOTICE TO A�PPLICANT:It,sMer maktng tM1ia Certificate�of CI7 TEL.NO. Expinptiori, you should become subject to the Workere' LAWN6PRINKLERSY6TEM STATE � LIQ� // faA Compensg4ion provisiom of�the Lahor Code,yau must forth- yVATER HEATER LICEN E NO. � CLASS C� Z � with-�comp'ly with�auch provWonK m tAis parmit shail be � - � . � - � desmed revoked. �. � - GAS SYSTEM OUTLETS DiSTRICT NO. PROCESSED BV LICEK3ED CONTkACTORS DECLARATION � �� - TI. V R i hereby�etfirm that I am licenaed under�yrovleiona ot Chapter S PER SYSTEM � . - �9(commencing w{tfi Section 76Q0)ot-LHvislon 3 ot tAe Buei- � � l ' F�NA� s. .VALIDATION nqa and Ptofeesiom-Code,sed mY licenpe is in tWl force and "T DATE X' y e(PecY.� � � � . �/��-,y� FINAL Licenae NumbeA�/ ,4u�a/�Z��c.Cl�aee�� - gy Cantrec�w��+�' /�1�t�� 17��_/ � � I am axEmpt from�the liceneing requ4ements 5s I am a P�en check fee � . licenaed uchitect or a tyiatered profeaioaal engineer pLUMBING PERMITl88l11NO REE S acting in my profe�sioaal capactty(3ection TO51, Bw- � inesa anA Proteseions Code). . . .ro7o�c�E . � Lic.or Reg.No. . -Date Plan ch�ek appliaa�t - HOMB OWTTER-BUILDER�ECLARATION Nem� . , . . ., � I hereby etfGm that I am exempt from the Contr¢Mor's '�a� � ' Licrnee Law tor the tollowing reeson ($ection 7031.5,Buei- CIW . � T�I,No. neas and Profes�iom Code):. � ��6 9 Jr A � I,aa ow�e�of�the property,em axcluaively conttacHna witA ticensed contractora to conatruct the project � . #� ��-�5 (S�Mion 7044,Bualneea end Rofeaaione Coda). � . � �;.".2Q$0 CONSTRUCTION LENDWG AGENCY . � . �,� �2 Q.�O� I.hereby �fflrm thet there if a conatruetion lending esency . for the parformance of the work for which this permit is � iasued(Sec.3099.Civ.CJ. - �. � � . - . - � � �� 7.'`8 w� Lender's N�me � " Lender's Addrees � . . I certify that I have nW thie epptication and rtate that the -� � . � above infprmatioq ie coaeM.I agree to comply with all County 3EE REVERSE FOR$iCPLANAiORY LAidGUAGE � - � ordinancea and Sts#e laws re;ulating Mum6ing, and hereby authoMze re0reeenutivec of ttiis CountY to enter upon the . - . above antionad property for inspactbn purpoaea. � - � � � � � etur" eT�e'�� D�_ ��^�� . . . � ��-> ��" � � wsvFCTOR's NorEs ' OWNER•BUILDER DECLARATION ��APPROVALS DATE �INSPECTORSSIGNATUqE . UN�ER S�AB WORK . � - ROUGH P�UMBING � � � - � - I hefCby affian that I am exempEfiom th¢Contractor's � . � LiCense�Lflw for tHe following ieaeon�(Section 7031.5, �qgp�� . . � � � - � ' Busrneas end Profeasions CodeJ: Any city or county Gns veN7 � , � - . . � . � � whrch requirea a permi� to constnict, atrer, improve, rrorYaq7ep�HE.o.T�R,.;. . demoli�h,or repair any structure,prior to i[s issucnee, Plui.�swG Flx7uHEs � �� •. also,requires,the app7icanr�jar such permii to jile a ` srgned:ataieyunt that rye is licensed;.pursuynt,ro the i Gas Tesr ��7.��Q1 . � - � provisrons af the Conrracror's License Law(Chopter 9 � UTILITY CO.NOTIFIED � � /CommenClAeg with Section 7000J of Division 3 oj rhe � � - � � � . . ' Business and Professions Code/ or that he is exempt Flnlqi. . ,�,��,.�,�,613p,�,t� .� � � therejrom and the basis jor fhe vlleged exempHow.Any , vrolation,oj Section 7031.5 by any apptican�jor a permit � .. ' �� ' � . - . � subjects th2 applecanr to a civil penalty nJnoi more than wousrR�.4� � .jipehundreddotlars.($50o).i . AS7�APPROVAL � -- � � �` . .. O[,as owner of the properfy will do the work,and . . � the stmcture is not intended or offered foi sale. � � ' � � � �� /See. 7044, Business and Projessions Code: TNe Con- �[z K � ' . . � , , � . - � � � . tractor's Lrcense Law dces not upp(y to an owner oj ' � �� . � �� - . property.who builds or improves rhereon,and who dces � ' -.' � such work himselj.provided thpt such improvements �� . � ` �� ' � � . are not intended o.ofjned jor sale, !J, however, lhe ,- � � � „ . - . bui/ding or lmprovement is sald wirhin one year oj '' • �� completion, the owner•bu!lder wi11 huve rhe burden � � � �� -- � � ' � . of provmg that he did not build or improve jor rhe purpose oJsale.� , �` ', � " I am exempt under Sec. , .'�, � �$&P.e.for Ihis reaspn�"'`• Date � Owner � INSPECTOR'S NOTES � . • • • • ,1. _ ..+ • � . - . .: . �. ., • . . ;� .