HomeMy WebLinkAbout1658A WORKERS'COMPENSATION�ECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby oiDpn.iAn�I!have a cerii(imie of consent to self 76A667A
ins�re,or o cerlifitofe of Workers"Compensalion Insurance, .CE 817�REV.10�81)
or a cenified copy thereof(Sec.9800, b.C.) COUNTY OF l0S ANGELES BUILDING AND SAfETY � �„�
P❑ol�icy No.Q��ompany - . U .
Cerlified mpy is here6y furnished.
❑ _ FOR APPLICANT TO FlLL IN(PRINT OR TVPE� bUILDING
Cerlified[opy is filed wit e couny buildi inspec- ADDRESS �
tion d parlment. ' NUMBER FIXTURE OR ITEM (rD FFE ����TM
a
WATER CLOSET NEAREST
�,pote Applica - �w '— _
�� CERTIFICATE OF EXEMPTION FROM W KERS' BATH Tue CrtOSS ST. ►����•^c
COMPENSATION INSURANCE � OWNER �Z �
�This��cfion n�ad not b�cemplat�d if th�work Invo ad SHOWFR
MAtL
thr p�rmif is for one hundr�d dolbn(5100)or I�a LAVATORY AD�RESS �
I certify tha�in�he pe�formance of ihe work for ' this
permit is issued,I sholl nat employ ony person fn any monner SiNK Cltt � TEL.NO. �'7��
so os 10 become su6jecl lo the Workeri Compensolion Laws. DISHWASHfR
CONiRACTOR
Date ' Applicont CtO7HE5 WASHER ADDRF55
NOTICE TO APPLICANT: If, oher moking this Cenificare oF ��
Exemption, you should become subject io the Workeri SWIMMINGPOOLRECEPTOR �
CITY TEI.NO. / 9
Compensotion provisions of�he lobor Code,you must forth- . �7Lh
LAWN SPRINKLFR SYSTiM
wiih comply �th wch provisions or this permil shall be SiaTE �'^� uG.
deemed revoked. - WATER HEATER LICENSE NO.� , /a CLASS
LICENSED CONTRACTORS DECLARATION �ISTRICT Np. PROCESSED BY '
I hereby affirm that I am licensed under provisions of Chop�er 9 GASSYSTEM OUTlETS p� �
(commencing with$ecrion 7000)of Divis�on�of rhe B�s�ness OUTIETS OVER v
and Proiessions Code,and my license is in full for�e/oyt d eHect. 5 aER SvSTEh� FINAL AIIDATION
Q n ( '`� DATE v• O
LicR�nse Numb ��+ `� Lic Class 'v ,
' � f" � � FINA U.�
Cdntroctor Da�e � BY ��
a
� I om exempl under Sec. �
B.BP.C.(or ihis reason W '.
Plan check fee ► n.�
Da�e: p�UMBING PERMIT ISSUING FEE E � Z�
Signature � �
TOTAL FEf G �� 6 5 8 A
Plan check opplicoM .
SINGLE FAMILY �• • • • •S
HOME OWNER-BUILDER DECLARATION . Name `
I hcrc6y efii:m!hc!�em e>e!np!hom rhn Cnntmctnr's license AdJress I • � �5 O
Law for the following reoson(SeUion 7031.5,Business and � • • j ���U
. Professions Code): C�fy Tel.No.
❑ I,os owner oi�he proper�y,will do the wark ond the � � �9.� 5�8 7
structure is nor intended or offered tor sale(Section ,
7044,Business and Prolessions Code). �
ICONSTRUCTION LENDING AGENCY
� I hereby�flirm�hot there is a conslruc�ion lending agancy for . . �
Ihe performance of Ihe work for which�his permit is issued
(Sec.3097.Civ.C.).
Lender's Name
i
lender's Addrens � -
I cer�ity�ha�I have read this oppl�ca�ion and sto�e that ihe � , �
above iniormation is corrett.I agree ro com y with all Counly � - � ,
ordinonces vnd State laws reguloting Plu bing,and hereby � . �
. outho epresemo��ve of�this Coun� to en�er apon the . . .
'<,obov -men�oned prop ry for insped� n purposes.
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