HomeMy WebLinkAbout1585A (9) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
I hereh;,cffirm-Ihat I hove a certificote of consent to self 20-0026DPW6/87
insure.�or o cert�ficote of Workers'Compensalion Ins�rance, 76A687A
or a cenified copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS � �I'�
o�li.W� ��Company��IJ� �7�,�J0
��j' Cert�fied copy is hereby furnished. �}
OFOR APPIICANi TO FIIL IN(PRINT OR iYPE) 6UILDING ��'1 �'9,m.�O ' rJ� �J�
Certified copy is filed wilh ihe county 6uilding inspec• ADDRESS L
fion departmenl. NUMBER FIXTURE OR ITFM � FEE ���ITY Q��7'/O (Sij/�+
Date N^�k'�� AppliSaN.����7 �L�� ` WATERQOSET 'f NEAREST � .
CERTIFICATE OF EXEMPiIpN FROM WORKERS' BATN TUB CROSS ST.
' COMPENSATION WSURANCE SHOWeR � OwNER �,�p,J �
(Th4��ctbn n��d not ba complal�d I!th�work involrod by /�
}h�p�rmtf i�for on�hundrod dollon(SI00)or I�u.) i U1VAiORY � qpp�RE� j Z V)/,�"'a'�O �� ����
I certify ihol in ihe performance of the work for which Ihis •
permil is iuued,I shall nol employ ony person in ony monner SINK � � GiY ���,.vY4 IS�' TEL.NO.
� so as to betome subjeu to the Workers'Campensation Laws. DiSHWASHER - �L�` � 1
� CONTRACTOR (;L L l,�S �(_
Dote�—�� � oPPlicanf `r�'`�y �Lny QOTHESWASHER AOORE55I31Z! ti�� �T`�Y�� ��
NOiICE TO APPIICANT: If, after mokina this Certificafe of
Esemption, you sbould become subjeU to the Workers' SwunMiNGaOOIRECEPfOR ^ -
Compensotion provieions of the lobor Code,you must forlh- GiTY �,,;�„���,;C r��.r,o. �63-;z.�3
wi�h comply with such provii�ons or ihis permit shall be �WNSPRIMlLERSYSTEM - STAiE UC. /�
deemed revoked, WnTER HEATER ���N�No.2s5 3 Z 3 Cu55 Cr—3�
LICENSED CONTRACTORS DECIARATION , �iSTRiR NO. ESSED BY
I hereby offirm thof I am licensed under Fxovisions of Chapler 9 GAS SVSTEM � QUTLEIS m
[/
(commencing wiih Seclion 7000)of Diwaion 3 of�he Business OUitEi50vER � .
� and Rofessions Code,and my licensg is in full force and effecl. 5 PER SYSTEM FINAL VALIDATION r
license Number Z�S�z3 Lic.Class C�3` DATE —(� � U
y�. �` ��y� BY A` ��� 4''
Comraclor �'��� � Dote � B3 C
❑ p;
I am exempr undar Sec. V
W
� B.BP.C.for this reoson a�
Plan check fee � v�
- ��e� -� PIUMBING PERMIT ISSUING FEE 5 a � �
Signature -
TOTAI FEE
' Plan check appliconl � �1 5 8 5 A
SINGLE FAMILY
HOME OWNER-BUILDER DECIARATION Name • �r• • • • •S
I hereby affirm lhot I am oxempt from Ihe Conhacror's litense qddress
Law for tha following reoson(Seclion 703L5,B�sineu ond . � • •L�S�
Profeuionf Code): �ity Tel.No. _
� •• •2850�
I,a�owner of the properiy,will do tha work and ths
mue�ure is not inranded or offered for sale�sa�ra� � . � 0 4,1 4—�8
T041,Busines�ond Profeaeiom Code). _ � •
CONSTRUCTION LENDING AGENCY • �
1 hareby nffirm thm Ibere is a conetruction lending ogenty for � ,
- �he performance of the work for whicb ihis permi�is Iseued
- (Sac.3097,Civ.C.). . . . .
� lender's Nome � � �
Lender i Addrese �
I teriify�haf I have read ihis application and stafe thai ihe �
obove information is corroct.I agrae io comply with oll County � � �
ordinances and S�o�e laws regula�ing Plumbing,and herehy • �
�horize repr anmtives of ihis Co y io enter upon the . - . �
- ove-mmtion � roperty far ins tion purposes:
SEE REVERSE FOR EXPIANATORY IANGUAGE
- �-1�-1—?Z
ure of Permit e Da�e
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