HomeMy WebLinkAbout0892A � WORKERS'COMPENSATION DECLARATION �usuw � �
�f herehy afPirm �aa� � he�e a'certl�cete of consent to self ��ce en(z-so) A P P L I C A T I O N FO R P L U M B I N G PE R M IT
insure,or a certificete ol Workers'Compensation Insurance,or
a certi£ed copy th�,{eof(Sec.3800,Lab.C.) '�
^/9L 9.S pToY/ � � ���1�. COUNTY OF LOS ANGELES BUILDING AND SAFETY '
. Policy No. Company � � '
❑ Certified copy is hereby futnished. . FOR AGPLICANT TO FILL IN IPRINT OH TVPE) BUILDING ) a
� Certified copy is fi�ed with the county building inspect�on � NUMBER FIXTURE OR ITEM • FEE A`DDRESS / {� IL 1 Z �
depe'me�� WqTER CLOSET LOCALITY ,
Date� 3 �Appilcant NEAREST
' - BATHTUB CROSSS
CERTIFICATE Of EXEMPTION PROM WORKERS'
. COMPENSATION[NSURANCE - SHOWER OWNER , �
IAVATORY MAIL � �n�
(This section need not be completed if the work invoWed pooRESS� GLM'- }
6y the permit is (rn one hundred dollars�(SI00)or less.) SINK Q!� CI7Y TEL.NO. �
1 certity thaf in the performance ot the work for which this DISHWASHER V
permit is issued,I shall not employ any peroon in any manner CONTHACTOH ��
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER AODRESS,O�' �- 0 '
Dete Applicant SWIMMING POOL RECEPTOR U
NOT[CE TO APPLICANT:If,aEter making this Certificate of CITV TEL.NO �
Exemplion, you should become subject to the Workers' LAWN SPRINKLER SVSTEM
Compensatinn prnvisions of the Labor Code,you must forth- STA7E L�C. j�
WATER HEATER LICENSE N 2 � CIASS f
with comD�9 with such provisions or this permit ahall be —
deemed revoked. � � GAS SVSTEM OUTLETS DISTRICT NO. VROC SED BV
� - LICFNSFDCONTRACTORSDECLARATION OUTLETSOVER D �C-t-�P� �
I hereby affirm that i am licensed under provisions of Chapter 5 PER SYSTEM ' �
9 (C�mmencing wilh Section 7000)of Division 3 of the Busi• � FINAI_ � 0 VALIDATION •
nesa and Professinns Code,and my license is in full force and DATE Q �
effecL q - n � � �
License Numher ✓"� 7 -Lic.Class� � FINAL . ;
BY
'Contractor Date
� I am exemD<<mm the licensing requ'vements a:t am a � Plan check fee
licensed architect or a registered profeuional engineer . pLUMBING PERMIT ISSUING FEE E � - •
acting in my profegsional capacity(Section 7051, Bus• . . _
iness and Protesaions Code). TOTAL FEE �{p �Q
:ic.o�Reg.No. Date Plan chack applicant
• HOME OWNER•BUILDER DECLARATION Name -� �
- hereby affirm that I am exempt trom the Contrector's Addren - � � - �^�n�^ .
.icense Law for the follnwin reason Section 703L5,Busi- � �v" ,•�n
g ( CitV TN.No. .
ess and Professions Code): � � ��,� � ���5 �
� I,as owner of the property,am exc�usively contracting � � - - .
, with licensed contracton to conetruct the project � � � � � � �Jr�
(Section 7044,Businws and Professions Code). _ . .
�- CONSTRUCTION LEND[NG AGENCY � � � � � �J�"
here6y affirm that there is a construction Iending agency � . f 2 Q Z�-H��
r the performance o(the work fot which ihis permit is . . , �
ued(Sec.3097,Civ.C.). �
- nder's Name
nder's Addreu -
�ertiTy that I have read ihis application end state that the
ive lnformation is correct.1 agree to comply with all County SF,F.REVERSE FOR EXPLANATORY LANGUAGE
'inances and State laws regulating Plum6ing, end hereby '
nze reprexntatives of this County to enter upon the -
-mmtione ;rop_erry for�tio purp�s� - � � .
O I��
�igmtureoPPemittee Date �
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