HomeMy WebLinkAbout1341A (7) WORKERS'COMPENSATIONOECLARATION APPLICATION FOR PLUMBING PERMIT � �
I hereby aftirm�hot I have a cerrifitate of consent to self 76ate7q
insvre,or a'cerli(icate af Workers'Compe�SaliDn InSuronce, GE BV(REV.�0/81) .
ar a certified copy�hereaf(Sec.3800,tob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
��az�s�t ��"-�F�,�
ocyNo Company �
Cerlified copy is here6y furnished.
❑ FOR APPLICANT TO FILI IN(PRINT OR TYPE) eUIL�ING ( ��v
Certified copy is filed wilh the couniy 6uilding inspec• A���� d�
tiondeparlment. NUMBER FIXTUREORITEM� Fd FEE ���ITY
�1p� WATERCLOSET K � �
Dale c���'C�qpplicant NEAREST
CERTIfICATE OF EXEMPTION FROM RS' BATH TUB CROSS ST, jF
� COMPENSATION INSURANCF pyy�q" `!
(Thb fetlfon npd not 6�templd�d tf tha work inrolr�d by SHoweR , , �
fA�p�rm�t is For on�h�ndred dolla�s(3100)or I��s.) LAVATORY q�pp�QEg ���s .�C S% ��
�I certify thal in�he perTormance of the work fm which Ihis � �
permil is if9ued,I shal�not employ ony person in any manner SINK � CITY ,U'� n F Gy TEI.NO. T a,�09
. ao as lo become subject to ihe Workers'Compenwlion Laws. DISHWASHER .
� CONTRACTOR' � �� .
po1E Applicant CLOTHES WASHER ADOxE55
NOTICE TO APPLICANT: If, af�er making this Certifica�e of S rr
Eaemplion, you ahould become su6ject lo the Workers' SWIMMINGPOOtREGEPTOR ��
CITY n TEL.NO.
CompCnsolion provisions of Ihe Lobor Code,you must foAh- �AWNSPRINKLERSYSTEM ��T
with comply wilh suth provisiont or this pe�mil shall be STATE C / LIC.
deemed ravoked. � WATERHEATER � ������� C�rJ(�a QA55 � y
. LICENSED CONTRACTORS DECLARATION D�STRKT NO� PROCESSED Bv
I hereby offirm rhot I om licensed under provislons oF Chapter 9 GAS SYSTEM OVTlEfS �
(commenting wi�h Setlion 7000)of Division 3 of the Business OU71E750VER �
and Profassions Cale,and my I�cense is in full forte ond effect. S vER SvsTenn F�NAL �1(;_�6 VA DATION
Ltcense Number�`��L2.C7�4�Lic Class� DATE l�lJ a��
� � - FINA � V�
Contraclor pote BY �'
� O
I am exempt under Sec.
9.8P.C.for ihis ieason W
Plan check fee p,
Da1e; pLUMBING PERMIT ISSUING FEE S LO �
Signoture � �'� J�� A Z.
TOTALFEE
' . Plan check opplicant �{•. a• e 5
� � SINGLE FAMILY .� • a��t 5�
HOME OWNER-BUILDER DECIARATION - Name II
I hereby of(irm thot I am exempt fram Ihe Conlroctoi s License. Address � �s � M e rt a K =
--d �_� 2 Sa %��v�. i7� 1 Q„0�
Law Eor tF- tol��wirg�ecscn(Section 7C�t.5.9�;�ra,;,.�� _ . .
Profesaions Code): City Tel.No. ��3 0 Q 2 7--8 6
❑ 1,os owner of the properfy,will do ihe work ond the '
st.uctu�e is not infended or o4fered for sole �Seclion �
704d,Business and Professions Code). �� '
CONSTRUCTIDN LENDING AGENCY . _ . . _
I hereby afiirm�hot Ihere is a conshuclion lending agency for
ihe performance of the work for which ihis permit is issued .
(Sec.3097.Civ.C.). � . .. .
lender's Nome
tender's Address � � � � �
I certify thot I have read�his application and sta�e ihat�he ►
obove informo�ion is correct.I agree ro comply wirh all Caonty � � - �
ordinances and S�ate lows regulating Plombing,and hereby
ou�harize representativez of�his Coonty to entei upon the - � � -
obo�e- enna�ed propeny ior inspeciion p�rposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
c�"'r — �7—,f��
Signature of�rn iq e Dote . . . . � .. .
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