HomeMy WebLinkAbout1051A (7) WORKERS'COM�ENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT 17
I hereby,offirm thol I have a cerlificale of consent to self 20�0026 DPW s/67 ���
insure,or a certificate of Workars'fompenmfion Insurance, 76A667A ��
ar o certif/ie�d copy thereof(Sec.3800,�6.C.) COUNTY OF lOS ANGELES DEPT.OF PUBLIC WORKS - �� �
P�ollcy NoI��QCompany J . �
Cerlified copy is hereby(urnithed.
� FOR APPIiCANT TO Filt IN(PRINT OR TY7E) BUII�ING /
Cerfified copy is filed wiih the county building inspec- nD�RE55 � i
tion de r�ment. NUMBER FI%TUREOR ITEM W FEE
����� �ocnun
Dole Applitonl WATERCLOSET � NFAREST , I y� '
C TIFICATE Of EXEM7TION FROM WORKERS' &4THTUB C�O555). �R�'v �/ � �
COMPENSATION INSURANCE OWNER �� ,�UZ�J-l�
(Thi�e�N�on eNd no/6�tompl�f�d ii fb�work�nvolr�d by SHOWER
Ih�p��mit i�for on�hundr�d dollan(f100)or lass.) iAvqTORv ��� $ �
�- ADDRE55
I certify tho�in the perfamonce of the work fw which this
permit is iu�ed,1 sholl not emptoy any person in a�y monner SINK G�iY TEt.NO.� � .
so af 10 become subject 10 1he Workers'Compenwtion Laws. DISHWASHER �
CONTRACTOR 'r
Dale Applicant QOTHES WASHER AppRE55 `
NOTICE TO APPLICANi: If, aher making this Certificote of [`
Erempiion, you should become subject to �he Workers' SWIMMINGpOpLRECEPTOR .
Compenwlion prorisions of fhe lobor Code,yo�must forth- ON TEL N0.6 ��
IAWN SPRINKLE4 SVSTfM
wilh tomply wifh Such provisions or fhis permit sholl be S7ATE LIC. '
deemed revoked. WATER HEATER LI�NSE NO. S� C1A55
LICENSED CONTRACTORS DECLARqiION DISiRIR NO. PI! D Y .
(hereby off�rm thot f om licensed under p.avisions of Chapter 9 WS SYSTEM OURETS t
(commencing with Settion 7000)of Division 3 of rhe Businass OunETSOVER -
end Professions Code,a�d my litense is in full force ond effect. 5 PER SvSTEM FINA VALIDATION }
Q� DAiE /- ,��� (1
llcense Number O u lic.Class � �
U
F�r �- � a
co�„a«o, Y oa�� o�
❑ 1 om ezempi under Set. V
B.BP.C.for thie renson � p�,�
Plan check fee N
�}�� 9LUM8ING PERMIT ISSUING fEE S S� z
Signature
TO7Al FEE
SINGLE FAMILY Plan check applicant � .
HOME OWNER•BUItDER DECLARATION Nome Z1
I hereby aHirm rhot 1 om ezempt from the Comracror's License Address �
Law fOr fhe following reason(Section 7031.5,Businecc on�
irofess�ons Code): City Tel.No. z� O�� A
❑ i,os owne�of the propeity,wi�l do the work and�he � -
structure ie nol intended or offared for wle (Section � �• • • • •5 '
70M1,Buslness and Professtons Code). � • •2 2,5�
CONSTRUCTION LENDING AGENCY
I I hereby nffirm tbol there is a canstrucrion lending ogency for • ° •L 2 J Q c�
the parformonca oF the work for which ihis permii is issued
(Sec.3097,Civ.C.J.
0823-38
Lender's Nome
Lender's Address �
I certify that I have read ihis applicalion and sia�e that the � .-
above informa�ion is correct.I ogree to mmply with oll Coun�y -
ordinances ond S�ole laws reguloling Pl�mbing,and hereby
au�h ':e repre�eN ives of this Co niy�o en�er upon Ihe . . �
obo e- enfioned�p perry For insp tion purposes.
� � �� SEE REVERSE FOR EXPLANATORY LANGUAGE
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