HomeMy WebLinkAbout1655A (15) WORKERS'COb{PHNSATION DECLARAT[ON �a��i�a � �
I hereby affirm �ha� 1 have a'certlficate oPconsent to 5e,� ��e.,�,=..a, APPLICATION FOR, PLUMBING PERMIT
insure,or a certificate nf Wnrkers'CompensaHon Insurence,or � . .
a certified copy thereof(Sec.3800,Lab.C.) � �I
vnlicy No. Z Z Company—S�A'�� �u^�p ' COUNTY OF LOS ANGELES BUI LDING AND SAFETY
i
� Certifled copy is hereby tumished. + FOR APPLICANT TO FILL IN(PRINT OR TYPE1 AODRESS 7.���/q, Lp}>
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� CertiTied copy is fiied with the county building inspection � Nl1MBER FiXTURE OR ITEM � FEE
�lepartme 1 I LOCALITY
S• �yt a'L T��p,r.��y� �1� � 7' i WATER CLOSET (� J aHIL
Date Applicant S— NEAREST y�n
� BATH TUB . CROSS ST. /[[q CjJ Cp� 'r�lA,I�j/q2 gL�-
CGRTIPICATE OP EXEMPTION FROM WORKERS' �
COMPENSATIONINSURANCE . SHOWER - . OWNER ��/�ub�LJGJ��. �2 Lt L�U12Lf')
MAIL
(This section need�not be completed if the work involved S �AVATOHY 0 U ADORESS p0. �d �.l a
by the permit is for one hundred doDazs (SI00)or less.) � stNK 0 d cirv D� �� '�fl� TEL.NO.�,s�,�'� O
f certify that in[he performance of the work fnr which this DISHWASHER �� TI'�A L�'L � �
permit is issued,f shall not employ any person in any manner CONTRACTOR
so as to become subJeet 1�the Workers'Compensalion Laws. CLOTHES WASHER ADDRESS��g3 KRPE � ��.VD
Date ADplica^t SWIMMING POOL RECEPTOR �
NOTICF TO APPLICANT:If,atter making this Certi�cate o( CITY kJqH�m TEL.NO.�-(j7 �
I;xemption, you should becnme subject to the Workers' LAWN SPRINKLER SYSTEM STA7E ? LIC. � z
Comprnsalion provisions of the Labor Code,you must forth- WATER HEATER LICENSE NO.JSS��I CLASS �"�
with comply with such provisions or this permit shali Ne � O
deemed revoked. � DISTRICT NO. PR ESSEO 8Y
� GAS SYSTEM OUTLETS p Q
LICENSID CONTRACTORS DECLARATiON OUTLETS OVER �D [�>-'�
1 hereby atfirm that I am Iicensed under provisions of Chapter 5 PER SVSTEM
9 (commencing with Sectian 7000)ot Division 3 of the Busi- FINAI �/ VALIDATION �
ness and Professions Code,and my license is in full force and DATE � �3
ef(ett.
License Num6er3S�Sy�7 Lic.Clau 3—� FINAL � .
9V
ConiractorrHRyC2- Date �"Z`'�'8Z
� I am ezempt from the licensing requiremenla as I am a Plan check fee �
licensed architect or a tegistered Drofessional engineer pLUMBING PERMIT ISSUING FEE E �
acting in my professional capacity (Seclion 7051, Bus-
iness and Professions Code). TOTAL FEE O �
Lic.or Reg.Nn. Date Plan check epplleent �
HOME OWNER•BUILDER DECLARATION NBTe �1 6 5 5 A
Address
1 hereby affrm that I am exempt from the Contractor's ��+�'�;���:�5
License Law for ihe following reeson(Seclion T03L5,Busi• - �ity Tsl.No. - � - -
ness and Professions Code): � •�•-5 6 5 0
, � ],as owner oP the property,am exNusiveiy contnaing � � . -� � �
with licensed contrectors to ronstruM the project � ••• •5 6 5 0 c=.o
(Section 7044,Business and Proteuions Code). .. '
0224-82.
CONSTRUCTION LENDING AGENCY . '
I hereby affirm that Ihere is a construction lending agency ,
for ihe performance of the work for which [his permit is �
issued(Sec,3097,Civ.CJ. . � , ' .
Lender's Name � .
LendePs Addresa � �
(certify that I have read this application and state that the � � �
above information is correct.1 agrre to comply wilh all County SEE REV ERSE POR EXPLANATORY LANGUAGL � - -
ordinanc and State laxm regulating Plumbing, and hereby .
authori epresentatives of this County to enter upon [he
above- e i ed perty for inspection purposes. � �
Z'Z.�_ � . - . . .
Signature of Permittee Date �
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