HomeMy WebLinkAbout1131A WORKERS'COMPF.NSATIONDECLARATION � )�A6�1A �-��,
I hereby affirm �hat 1 have 7 certiPcate of�o�5�� �o s��� � �E.,,�=-sor APPLICATION FQR PLUMBING PERMIT ��
insurc,or a certificate of Workers'Compensation Insurance,or ` . . . . - .
a certif d copy thereof(Sec.3800,Lab.C.) �
Cu�,!'�—l3 i'�''�!' A /I ' COUNTY OF LOS ANGELES BUILDING AND SAFETY'
P�olicy No. ComOanY ��Pn,«,,,/ .Jrr-A�. .i � . . . .
yY Certifled copy is hereby furnished. ! FOR APPLICANT TO FIIL IN(PRINT OF TYPE) BUILDING �,` � J �/1 AA� _�Q�
(O AOORESS [//V! .>>�� .1
Cettified copy is fiied with the counfy building ins fion NUMBER FIXIURE OR IlEM • FEE
AepartmenL � LOC/�UTY ' a�
Z WATER CLOSET � b
Dste Applicant NEAREST �j
� ' BATH TUB CROSS ST.- �3 /C-W '
CERTIFiCATE OF EXE PTION FROM W RKERS' � �
. COMPENSATION[NSURANCE SHOWER OWNER �
MAIL
(Thts aeC600 need t1o�b!COmpIttld 1(th!wOIk tt1�'ONld LAVATORV � Q AODRESS C �
by the pecmit ia fm one hundrod dotlara (SI00)or less.) � SINK �
� Q CITY TEL.NO.. O
•li certify that in the Derformance ot the work for which this � DiSHWASNER 7-A t� .�c�v i 1C^ � �
�permit is issued,I shall not employ any peraon in any manner , CONTqACTOR �� J .��) �
so as to 6ecome subjett to the Workas'Compensa[ion Laws. CLO7HE5 WASHER � �"" � �
ADDRESS Q � ��y
Date Ayplicant " W •
SWIMMING POOL RECEPTOR D�r�A'�� � ��� N
NOTICE TO APPLICANT:If,after making this Cenificate o( CITV i� /� TEL.N
Exemption, you should become subject ta the Workers' LAWNSPRINKLERSVSTEM STATE �/ LIC. Z '
Compensation provuions of the L�bor Code,you must forth• : yVqTER HEATEH (� LICENSE NO.��/� r0 ClA3S ��� -
with comply with such provisions or this permit shall be �. Q -
deemed revoked. � GAS S�STEM OU7LETS O U DISTRICT NO. PROC�53ED BV �
LICENSED CONTRAC70R5 DF.CLARATION � OUT�ETS OVER /Q (Z.uQ�/ .
1 hereby eiflrm that 1 am licensed under provisions of Chapler 5 PE R SVSTEM � .
9(commencing with Section 7000)of Division J ot the Busi• � � - /, FINAL �/�(�/�L
ness and 1'rofesaions Code,end my license is in full[orce and 4' � DATE 7 � VALIDATION _
effect. � � CQ �
� FINAL� �
License Number C U Lic.Ciass �—� d BY ` �¢�,.,_
��'���
ContreCto L� ale .
� I am ezempt from the littnsing requ'vements aa 1 am a + Plan check fee _ � ,
iicensed architect or a regintertd profeuional engineer pLUMBING PERMIT ISSUING FEE S l
acting in my profasional capacify(Seciwn 705t,Bus• _
inets and I'rofeuions Code). TOTAL FEE a .�� .
Lic.or Neg.No. Date � Plan check a0vlicent ' .
HOM[OWNER-HUIL�ER DECLARATION Neme �
I hereby atPvm ihat I am exempt from the Contrector's Address $� � 3,� A
Lir•���Law fc::":fc:!c�.ing ttascn iSection.;C3i.5�Susi• . CitY TaI.No. �
ness and Professions Code): � �.��� � �5
� I,as owner of the pro0erty,am exclusively contracting � • � 2 Q,5�
with Iicenced contractors to conatruct the project . � ,
(Section 7044,Businesa and Professions Code). • � � ��Jr O�
CONSTRUCTION LENDING AGENCY . � �2 2�-8�
1 hereby affirm that there Is o construction lending agency �� . �
for the per(armence of the work for which this permit,is � , � �
iasued(Sec.3097,Civ.CJ. � � � �
Lender's Name �
LendePs Address � �
I certify that I have read this a00�ication end stau that the �
� above information is correc4 I aQree to comply u�ilh all County � SEE REVERSF,FOR 6%PLANATORY LANGUACE -
ordinances and State Iaws reguleting Plumbing, and hero6y ! �
aulhorize representatives of this County to enter upon the �
above-mentioned property f r'nspecti� purposes. � - � � �
�—�/ �
nature of Per ittee Uate '
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