HomeMy WebLinkAbout1542A � ' WORKCRS'COMPENSA'CION DF.CLARATION �� � �swssow . � ,. �. .
� h���ny ��ffirm �h�� I have ��trt;�;���e �f consent to se�f �E a,��=-ao, A P P L I C A T10 N FO R P L U M B I N G :.PE R M I T
� insure,or a certificate uf Workers'Compensation Insur,ance,or � . � �� � � - �-' .
a certified copy thereof(Sec.380Q La6.G) � � � � '
�� � ��� COUNTY OF LOS ANGELES BUI LDfNG AND SAFETY
Policy N �'�i�� ComPany . . . .
�Certified copy ie heteby fu[aished. f''v� Iqr'3- FOR APPLiCANT TO FILL IN(PHINT ORTVPE) BUILDING �� ``� ��;� r�
� ADDRESS �ia� L ..
Certif�ed copy is fited with the county building inspection �� NUMBER FIXTURE OR I7EM � FEE
llat�depar men. t� ��� � WqTER CLOSET G LOCAU7V r .
.ApPlicant� �� Ub1I/h—. � / � NEAREST � .
BATH TUB CROSS ST. (t..� ' : 1
C�RTIFiCATE OF EXiSMNTION 7'ROM WOIiKERS' /�p�/� �
COMYCNSAT70N INSURANCE. SHOWER OW�fER '
� M A I L,—"'��`
,:(This SectlOn need uot he completed iP the Work tRVolved � LAVATORY � �� ADDRESS
— —�LD_eS�� � ;,.'
by [he permit.is for one hundced dollars ($100)or less.) SINK p r� r� -
. . . p L_5� GTY�,'," �� ., .. �_. TEL.NO. i,�,��
I cer�ify ihat in the perfm�m.�nce of the x�ork for which[��i.s DISHWASHEF2 CONT�R AT OR����JKs I��' ��
permit is issued,[sh�ll not employ any person in any manncr
w as to beCome suUject io the Woskecs'(:ompensahon Laws. CLOTHES WASHER ���
ADDRESS �+�Q � � �'��- �
�1Jate APplicant � � ���_�.
SWIMMING POOL RECEPTOR
NOTICR CO APl'I.ICANT:iF,after making thts Certificate of CIT . � � T � .�f` �j
.�.�xemption, yuu s7iould become subject tu tlie Workers' LAWNSPRINKLERSYSTEM �% �
�-�Com ens�iwn rovisions of the Labor Code,you must forth- STATE ��QL.:y{ U0. � y t�,2�
� p ���3 LfCENSE NOp4)r [ f� J�
. with comply with such prbvisions or [his permit 5huli be � WATER HEATER l.4 CLASS ��� �
'.��dcemed revoked. � GAS SYSTEM°'7 OUTLETS O^` P�STRICT NO. 7R0 ESSED BY �A--
LICENSF:U CONTRACTORS DECI,ARA'l1UN V + � �� �
OUTLETS OVER �1 n\ `� ��� �, .
. 1 hereby a4firm that 1 am licensed under provisions of Chuptcr 6 PER SYSTEM y'K.� � v i �..
� 9 (rommencing wiih Section 7000)of[7ivision 3 uf the pusi- �. s� �t (�� FiNAL ���� j�� VALIDATION .
� �ness and Professions'Code,and my license is in Suil forcc and l :i��Y.�.SV DATE 1 '
� effect. �
� /t j� PINAL�. r ...
' Li�ense Numb�� Lic-Class_! '"�p.. — gy {��.`�.�'�qµJ �
( �"�t'_��
�Contructor��%Jf_y=— Date . . , .
,.� (um exempt erom the Iicensing requicements as 1 nm a � Plan cheCk fee � , .
licensed architect or .� registeied professional engi.peer pLUMBING PERMIT ISSUING FEE$ � � - -
acting irt my professional cupacitY'(Section 7051,Bus- �
iness and 1?ofessions Code). � ' � . TOTAL FEE S� . . ,
:��I..ic.ot Reg.No._ llate . Plan check applicant � - �
HOMB OWNhIt-HUILDF,12 DL;CLARA7'ION Nsme �
�.-I tiereby affitm that I am exempt from the Contcactot's ��� pdtlress� _ ' .
.LiCenae Law fur the foll��w�..g . sen !Sec!i.^.r. 7^3:5, 3u.;: �.Lty Tel.No. 'y �i
{ �ne>s anJ Professim�s Code): - �� �J/.�,Q{� ..,I
I;�� I,es owner nf the property,Am exclu5ively contractirtg �� ��� � ' � �5
I • with licensed contraMurs to construc[ the projeCt , '! �
f (Sectton 7044,.IIusiuess and Pcofessions Code). ^�
' f o •98,5Q
:: F,
CONS'1'RUCTION LL•'NDING AGGNCY � (�� °�° e�J$„S,O=
.:�-i Itereby afTirm tha[there is a construction I�nJing agcrtcy . . y,. . .
=.:;fot the performenec of the work for which tliis perini[ ia � �,z,� t '`8?
�issued(Sec.30v7,Civ.C.). ' � .
�'Ixnder's Name _ � ~
�i ' .
�_'`Lender's Addrzss �
���:I certify that I have read this applicatiun and stflte tliat the - ._.
��above information is correct.I agr�e to cumply with all County � SEH RF,V IiRSE FpR LXYLANATOKY I.ANCiUAGF.
:,��ordinnnces ;ind State l�ws regul.rting P)umbing, and herebY , -
'''�.uuthurize repr��cn[atives of this Connty to�enter upon the . •
dabove-mentioned pr perty jbr inspectio9.yly_r oses. � - .. .
� �. �
�gnature of Peuuittee Uat � % , 't
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