HomeMy WebLinkAbout1298A (20) WORKERS"COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT n
1 hereby offirm thal I have o certificate of consenl to self 20-0026�PW 8/87 c 1
_ insure,or a certificate of Workers Compensaiion Insurance, 76A667A ��
or a cenified copy ihereof(Sec.3800.Lob.C.) COUNTY OF LOS ANGELES DEPT.OF PUBIIC WORKS ��
P❑olicy No.t11L71dLCompony . . � � �/�
Certified copy is hereby furnished. ���J�
OFOR APPLICANT TO FILL IN(PRINT OR TYPE) 8�����' �� I
Certified copy is filed wilh the tounty build�ng inspec• ADDRESS
liond partment. f� NUMBER FIXTUREORItEM � FEE ����tY �
� Dafe�.LAppliSoni ���� v� (/ WATERClOSET � NEAREST �
� CERTIFICATE OF ExEMPTIQN FROM WORKERS' BATH Tue CROSS 57.
COMPENSATION INSURANCE OWNER
(Thi�r�clion nard not ba compl�tod 1!tha work Inrolrad by SHOwER
Ih�p�rmil b for on�hundr�d dollon(5100�or las�.) inVarortr �'��
� ,Z, AWRESS �
1 cerfify thal in the perfamance oi ihe work for which ihis
permil is issuad,I sholl not employ ony person in any monner � SINK t� CITY. TEI.NO.- O
so as to become subject io�he Workers'Compenwtion Lows. Di5HwA5HER �
c.avrw,aoa /�p Y
Date epplicanl CLOTHES WASHER n ^ ny I
C ADDRf55 _�
NO110E TG A?PiiC,ANT; if, fter rck�n-y thi:Cer!ificale of ! J' �J(
Exemption, you should become subject to ihe Workers' swvaMiivGn�iRiCiiiGR Cltt iEl,Np��
Compen5ofion provisions of Ih6 labo�Code,you musl forlh- UWN$PRINKLER SYSIEM
with mmply with such provfe(ons or �his permi� shall 6e STA7E liC.
deemed�evoked. WATER HEATER u�rw. S7 cuss
LICENSED CONTRACTORS OECLARATION , oiSTkiCT NO. rROCE55ED BY
1 hereby affirm that I am licensad under provisions of Chopter 9 G/+5 SYSTFM OUttEis /�
. (commenNng with Seaion 7W0)of Divislon 3 of tha B�s�ness pUTlET50VER �
ond Profeasions Code,and my I�ceme is in full face and effeU. 5 aEa SrS7Ern
n�y .� DATEL V LIDATION 0.
� license Number �gs?U 7S Lic.Closs �
' FINAL U
CoNwctor pote BY �
❑ 1 om exempt under Sec. V
� B.&P.C.for this reawn Wi
Plan check fee � �'
�
Dare: PLUMBING PERMIT ISSUING FEE; !�` Z
Signoture +1
TOTAL FEE (N � z 1 2 4.8 F !�,
Plan check applicant �• • . • .5 '.f
� SINGLE fAMIIY
HOME OWNER-BUILDER DECLARATION Nome LU1 � • � Q Q S O
(. I heraby offirm tho�I om exempt from tha Contractor's License qddress
law for�he following reaton(Seclion 7031.5,Business and . . . • � C G .rJ G�
Pro}essionn Code): City Tel.No. 7 � �
❑ I,va owner of the propeny,wil�do rhe work and the � O�3�—H 8
strucNre is not intended or offered fof sale,(Seclion �
7044,Businesz and Professions Code�.
LONSTRUCTION IENDING AGENCY
I hereby affirm IMt there is a conatruction lending agency for � �
the performance of the work for which this permit is issued
. (Sec.3097.Civ.C.).
Lender's Nome � - � -
lender's Address _ - "
1 cerfify�hat I have read ihis applimtion and siate thai the . � - �
above information is correU.I ogree lo comply with all County -
ordinoncas and Sta�a lows reguloting Plumbing,ond hereby .
out n repreleNati e of this County lo enter upon the
ob ve- ntioned pro r�y for i�spa on purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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, Signature of Perm t e Da�e
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