HomeMy WebLinkAbout1077A (5) l WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT /7
� I hereby offirm lhot I have a certificate of consent to self 20�0026 DPW 6/67 G�
insure,or a[ertificale of Wo.kers'Compensation Ins�ronce, 76A867A I 1
or a ce�tified copy�hereoF(Sec 3800,La6.C.) COUNTY OF LOS ANGELES DEPT.OF PUBUC WORKS U
P❑olity No. Company -
Certified copy Is hereby furniahed.
❑ FORAPPLIGNTTOFILL W�PRINTORTYPE) ENLDING �SO N• (
Cerliiied copy ii filed with the county boilding inspoc- ���� � "'
tlon deporfinent. NUMEER FIXTURE OR IIEM � FEE �
� I LOCALITV �_
Date qpplitnnt W�TERCLOSET l0 Q NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB C�i055 ST. •
COMPENSATIONINSURANCE SHOWER �W�R Dd-� T r r� ��-
ll,a 74 S S/o ti
(Thh uerlon nNd no1 b�eompbbd if�h�work Involr�d by �
�M p�rmlf b for on�hundnd dollan�SI00)or bo.) uvai0av Q A�DDRE55- U N• � ' �
I certify rhat in Ihe performonce of rhe work for which�his . �
permlt is Isfued,I�hall nof employ ony per�on in ony monner SINK 0 CITY TEL.N0.
to as lo become cubject to fhe Workers' om e aotipn Laws. DISHWASHER
%V COMRACTOR ' L(/'^+ L✓C s
Daro `�7� pplitonl � CLOTHFS WASHER ADDREu � �
NOTICE TO APPLICANT: If, aNer moking �h Cenifito�e of $yyIMMING POOt RKEPTOR ��� /• ��
Exemption, you should become sub�ect fo rhe Workeri
COmpenfolion provislons of the labo�Code,you must forfh• UWN SPRINKIER SYSTfM CIN x � � TEL.NO.�,�`a_�)
with comply with tuch pro�iilons o� �hts permi� shol� be S�N�� b p Q 7 s CG.� Gt,_3
dOemed re�oked, Wq7ER NEATER �
LICENSED CONTRACTORS DECLARATION DISiRiC7'Nq. `_ _ D Bv
I here6y aHirm tFa�I am liceroed under provisioas of Chap�er 9 GAS SYSTEM OUTLFfS . `j �\ �
(commencing with Setlion 7000)of Divition 3 of�he Business p�i�EiSpyEp
and Rofemions Code,and my licensa is in full force and eHect � - 5 vER Svsienn � � F�NA� ,/ � a'
eD /��'� (., V VALIDAT�ON O
license Num6er�� /�7� c.Closa� DATE / .i�
j�PG,..�i r.��J BY A� U
C rattor Oate �
O
I om exempf under Set. � (~j
B.dP.C.for this reason S� �'^ � Q-'
Plan check fae v� '
_ . � te: •�`SL � =.
Siqnoture /1..,�• PIUMBING PERMIT ISSUING FEE S �O �
TOTAI FEE
- � Plon chet4 opplicant � �
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name .
I hereby ofiirm Ibot I am ezempt irom tha Contractor's Licanse Addrwss - =1 (1 7,%fl �
Law for tF.e fc!!cw:rg reoscn(Secilon 7C71.5,Susiness and � � �
Professions Code): Ciy Te4.No. . �• • • . .5 �
❑ I,os owner o(Ihe property,will do the work and ihe ' • •v�J O
shutture is not in�ended or oHered for sole(Section , . .
70d�,Business ond Professions Code). •5 8.5 0�
LONSTRUCTION LENDING AGENCY .
I hereby affirm fhot there Is a consfr�ction lending agenty for 0 Q 2 Q—8 8
the periormance of 1he work for which this permil is iuued � � " .
(Sea 3097.Civ.C.). -
Lender's Nome '
Lender i Address �
I ce�tify�hot I hove read Ihis opplication ond sta�e Ihot the � ,
abave informalion is correct.I agree io mmply with all Coonly
ordinances and Sro�e laws regulating Plumbing,and hereby . �
authori e�e r entatives of�his Coun�y to enter upon thc . �
�e- emi e erty for�nspection purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE
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