HomeMy WebLinkAbout0654A ~WORNERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT /—�
J ' � 20.0026 DPW 4/87 . . . �
I hereby,affirm that I have a certifimte of mnsent to self in- ��ya�A . .
sure,or o certificate of Workers'Compensafian Insuronce,or a CE 817�REV.B!B6� - �-
cartifiad copy the�eof(Sec.3800,Lob.�C) . �� /
Polky No. 53 Company�'���`�^+4 �OUNTY OF lOS ANGELES DEPT.OF PUBUC WORKS
�� Cartified copy is hereby iurnished. .
FOR APPIICANi TO FILL W(�RINT OR TYPE) - BUIIDiNG� �A
�Cerlified copy is filed wiih e coun buildi ins ction . ADDRE55 7
dep��lme�1. . NUMBER FI%TURE OR ITEM C FEE
1 IOCAUTY �
Dole {'� � I Appl� ni. WATER ClOSET�TOttE7� NEAREST . -
CERTIF�CAlE OF EXEMPTION FROM WORKERS"� BATH TUB CROSS ST.
� � COMPENSATION INSURANCE SHOWER OV�NER �
(This f�ttion n��d no1 bs templat�d(i th�work involvod by �ii
}he p�rm�t is!or on�hundr�d dallen(SIOO)of IBs.) ' LAVATORV - ADDRE55 S�� �
I certify Ihal in fhe performance of the work for which ihis per- - SiNK �
mit Is issued,I shall nol employ any person in any manner so - CITY � TEL.NO.
os to become subject to the Worke�s'Compensation laws. DISHWASHER
, . CONTRACTOR � � ���� �„�S
Da�e Applican� '- � CIOiHE5WA5HER S I-�Dl..�� �- �
NOTICE TO APPLICAN7:If,ofte�making lhis Certificate of Ex- � ADDRE
� �ampfion,you should become subjeU lo the Workars'Compen- SWIMMING 7001 RECEPTOR CITY ���., T T L.�j�s'
�sation provisions of the Labor Code,you mu5�(orthwiih comp- �,4WN SPRINKIER SYSTEM O� ' ' v �_ �
ly wi�h s�ch provis�ons or ihis pe�mit sholl be deemed revok- STnrE ¢�S A uC. �
BCJ. �- � � � WATER HEATER LICENSE NO. � CLA55
. . LICENSED CONTRACTORS DECLARATION � � DISTRICT NO. PROCESSED BV
I hereby aifirm Iha�I am litensed under provisions of Chaple� Ga5 Svsieh� OUiIEiS �
9(commencing with$eUion 7000)of Division 3 of the B�siness OU7lET5 OVER
and Professions Code,ond my license is in full forte pnd eF- � 5 PER SvSTEnn� FI . � AUDATION y
� fecL � � Q � � A O
License Number ���v��Lia Class� . . V
�`�,,�� FINAL p�
Contrac���QOs�����b'ade �� �� � BY � � 0
� I am exempt r . U
W
a
a.BP.C.f this reason plan check fee , z
DO�e� — � PWMBING PERMIT ISSUING FEE S �tl �J�
Signo�u TOTAL FEE � �0 6 5�4 Fl
� � SINGLE FAMILY plan check appliconl � � �� �• � • . .5
� HOME OWNER-BUILDER DECLARATION
I hereby affirm�hat I am exempt from Ihe Coniroclar's License Name � - � • e L 2 5�
Law for ihe following reoson(SeUion 7031.5,Business and .
� Professions CodeJ: Address � ` � � _
. - •Cz...Oc�
� I,os owner of the property,will do Ihe work and 1he �'�Y TeL No. - ,
strucrure is no�in�ended or offe�ed for sole(Settion 7044;� . . 0&��/—��
�Business and Proiess�ons Code). � �� � . ► .
CONSTRUCTION LENDING AGENCY - � ' - �
I hereby affirm ihat Ihere is a conslruUion lending agency far � � � �
. the performance of the work for which this permit is issued
� (Sec.3097,Civ.C.). � . � .
Lender's Name . � �
Lend ress � � �
� I artify that I ve read this opplicalion and state�hot Ihe . �. � � � � , �
bove iniormalio is correcL I ee to comply with all County .
rdinonce a�d S� �e la egul ting Plum6ing,and hereby � - � � -
authoriz eprase at� s of County to emer upon �he
6ov e ti ed r perry r in ction purposes. , � , . - ,�
�����Q - SEE REVERSE FOR EXPLANATORY IANGUAGE
v ;�
� SignaWre of Permil e Dote � �
� ���
APPROYALS DA7E IN57ECTOR'SSIGNATURE � INSPECTOR'S NO7ES � �. OWNER�BUiLDER DECLARATION.,. . �-
UNDER SLAB WORK - . . . ,( hBlBby 811kR1 ihet-I�elli B%BRlpt hOrtl th6 CORIfdCt0�5
ROUGHPLl1MBING ��Cb(1!B Law'for.the tollawlnp f9B9p11 (Section.7037.5,
. Business and Professions Code). Aoy cRy or county
cns aiaiNc ; - �• , - - wblch requires a permlt to construcL alter, lmprove,
cns vENT . demolish or repair any slructure,pdor to its Issuaace,
HOT wnrea HenTea . a(so requires the applicant tor such peimit to file a signed
a�un+aiHc FixTuaes siafement that he is/icensed pursuant ro rhe provlsrons
ot the Contracfor's License Law(Chapter 9(commencing
cas resr Z � wrth Section 7000)of ONlsfon 3 af the Business anrf Pro-
uriun co.NOTiFleo tessions Cotle)o�fnaf he is exempt therelrom and the
_. basrs tor the alleged exempiion.Any viofation oi Secfion
7031.5 by any applicant ioi a permit sub�ects the appli-
FINAL �'nter on�ront � � � � � - � � � - � . cant ro a civl/penatty o�not more than 6ve huntlretl
tlollers($500)..
INDUSTRIAL . . . � � . . . . Q 1,86 OW(IGf O(Lh6 p(Op91�y WIII tl0�hB WOr1c.afN11hE
WASTE APPROVAL � � - ' � � � ' � BffUCtI1fB i8 001 1111911dBd Of ON6l9d fOf 9318.
(Sec.7044,8usfness end Prolessions Code:The Contrac-
tor's license Law does no!apply to art owner of propeRy
' , who builds or lmproves fhereon,antl who tloes such wark
himseff provided that such rmprovements are not]ntend-
, • , etl or oNe�ed tor sale.ft,however,fhe building or im-
� provement is soltl within one year of completion, the
�1 owner-builder wi!!have the burden o�proving that he d!tl
• nof build or improve fo�ihe purpoae oi sale.)
\ I am exempt under Sec.
� . , . B R P.C.for thta reason
Date
. Owner
INSPECTOR'S NOTES
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