HomeMy WebLinkAbout0853A WORKERS'COMFF.NSATIOYDECLARATION � �e�ea� � APPLICA�TION FOR PLUMBING .PERMIT ,r�
1 hereby sffirm that I have a'cerlificete of consent fo seif cE ev Iz-eo
insure,or a certificate of Wnrkers'Compensation Insurance,or ' � � � ' I
a certifed copy thereof(Sec.3800,Lah.C-) . ' - " � �J " �
PoGcy No,�.��:�mpany�F�S �✓� COUNTY OF LOS Af�l(�'ELES BUI LDING QND SAFE Y
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� Certified copy is herehy furnished. FOR APPLICANT TO FII.L IN(PRINT OR TYPE) ADIDRESS ,�i' Qi g p((/Q �
� Cerlified copy is filed with the county building inspection NLIMBER FIXTURE OR ITEM • FEE
department. LOCALITY D/�. ud .
WATER CLOSET
Date Applicant � � NEAREST n �-
BATH TUB CROSS ST. �g � �
CERTIFICATE OF EXL•'.1PTION FROM WORKL•'RS'
COMPGNSATION INSURANCE SHOWER OWNER �. V - .
LAVATORY MAIL }
(This section need not be completeA if the work involved n U aODAess ,S 4� . O
by the permit is for one hundred dollars(5100)oi las.) SINK �(J _
CITY �.0 � TEL NO. U
I certify that in the performance of the work for which Ihis pi5HWA5HER r� �
permit is issued,I shali not employ any person in any manner e CONTRACTOR��� L� O ,
so as to 6ecome subject to the Workers'Compensetion Laws. CLO7HE5 WASHEF AODRE55 U� �
Date Applicant �3 B 6 � s
SWIMMING PDOL RECEVTOR CITY r 7� �
NOTICE TO APYLICANT:If,after making this Certificate of ��q��f �py ,� TEL.NO. y9e c17
Exemption, you should become subject to the Workers' LAWNSPHINKLERSVSTEM STATE LiC. z
Co!npe.^.<_3tion previeior.s of th:Latcr Code,you must fo�qo- / yypTER HEATER � LICENSE NO, (� c�nss G3E-G�/ �
with comply x•ith such provisions or this permit shatl be ,
deemedrevoked. � GASSYSTEM � OUTLETS ��� DISTRICTNO. PROCESSEDBY
-LICENSF.0 CONTRACTORS�ECLARATION OUTLETS OVER '1 /Q �¢�,�q� �
I hereby affirm that I am licensed under provisions of Chapter � 5 PER SYSTEM �C/ .
9(commencing with Section 7000)of Di}�ision 3 of the Busi- I I, FINAL � � VALIDATION
ness and Professinns Code,and my Iicense is in tull force and �{ /�✓ r �v DATE a,� a ,
effect. � � /—�00/e $��t/ U�
License Number � � Lic.Class�C 3�G����y FINAL
� ✓ Q(J 6 V
7<�a�zyt.�..A,p.w,a /1—.30-8(
Contrector Date
� I am exempt from the licensing requirements as[am a � Plan cheek fee .
licensed architect or a registered profeuional engineer pLUMBING PERMIT ISSUING FEE S � �
_ actinR in my ptoPessional capaciry(Seetion 7051, Bus-
iness and Rofessions Code). � � TOTAL FEE s !Q
Lic,or Res.No. Dete Plan check applicant
IiOME OWNER-BUIL�ER DECLARATION Name . ,
1 hereby affirm thst I am exempt from the Contracto�'e Addra�s � �Q�,�3�
License La�v for the following reason (Section.7031.5,Busi• City Tel,No. -�� � �.���Jr .
ness and PrafeSsions Code): , . .
� ],as owner ot the property,am exclusively contractlng . � ' � � • •5'�.5�
wilh licensed contractors to construct the pmject - � �
(Section 7044,6usiness and Yrofeasions Code). � � " � � � y,� •Jr 7,rJ O� . .
CONSiRUCT10N LENDINC AGENCY " � I �,3 O—8� '
� ! hereby alfirm that Ihere is a consUuction iending agcncy � �
for the performance ot the work for w�hich this permit is
� �issued(Sec.3097,Civ.C.). �
l.ender's Name
LendeNs Address
I certify that 1 hnve read this application and 51ate that ihe �
ahove infqrmation is correct.1 agree to comply w�ith all County : StiE REVERSE 1'OR EXPLANATORY LANGUAGE �
ardinances and State laws regula�ing Nlumbing, and hereby :
authorize repreuntatives of this County to enter upon the . .
a6nve•m oned pro erty for ninspection purposes. . '
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