HomeMy WebLinkAbout1673A WORKERS'COMPENSATION DFCLARATION �e�sn� � �
I hereby affirm tha� � ha�� a•certificate o[consert tn Se�� �E.�,�=-.a, APPLICATION FOR PLUMBING PERMIT
insure,or a tt�tltieate of Workers'Compenaalion Insurantt,or � . � ,
�jertiPed copy}qq��fhh♦♦�ereo[(Se 3800.Lab. . COUNTY OF LOS ANGELES BUILDfNG QND SAFETY
AiAic�f�.�C�anY ' ��� � .. -
�Certifed copy is hereby furn�shed. FOR APPLICANT TO FILL IN(PRINT OR 7VPE) qOOIiESS ,/� '
� Certifiel coOY�f�ed wilh e c unly building i pectian NUMB R FIXTURE OR ITEM � FEE ,
�le atm O� LOCALITY d _ �
WATER CLOSET
Date pplicant NEAREST
' BATN TUB CROSS ST. " �
C'RTI 1CATE OF EXE ON OM WORKERS' � SHOWER aWNER
COMPCNSAT [N5URANCG
LAVATORY . � MAIL . � -
(Phis section need not be compieted it the work invotved nDDRESS � }
by the pe[mit is for oae hundred dollars (SI00)ar lexc.) SINK � �� CITV � TEL.NO. �'
O
1 certify that in the per(ormance of the work For which this �I5HWASHEH CONTRACTOR V �
permit is issued,1 shall not employ any person in any manner Lr ��
so as to become subl¢ct to the Workers'Compensation Laws. CLOTHES WASHER ADDRE55 � -
�ate ApPlicant ' SWIMMING POOL RECEPTOR � V `
��NOTICE TO APPLICANT:If,aiter making lhis Certificate of CITY TEL.N _
ExemQtion, yoU should hecome subject lo the Workers' LAWN SPRINKLER SYSTEM STATE L��� /. 3 z 1
}Compensation provisions of the Labnr Code,you must for[h• yyqTEfi HEATER LICENSE NO. CLASS �.— '
with complY with such provisions or this permit shall be DISTFICT NO. P CESSED eY
' deemedrevoked. � GASSVSTEM OUTLETS �
LICENSE�CONTRACTORS DECLARATiON OUTLETS OVEH � O [ZLL��
1 hereby eff'vm that 1 am licensed under provisions of Chapter 5 PER SYSTEM . . �-
9(corqmencing with Section 7000)of Division 3 of the Busi� � ' FINAL� ��� �� VALIDATION � �
ness and Pmfessions Code,and my license is in tull Porce and DATE
efiect. � � �
C � / FINAL ��.-�" '
Licens umber ic.Class G � gY " rt�1'+<�'.,f
Cnn r e
� 1 am exempt from the Iic sing requi ments as 1 em a Plan eheck fee '1 �
licenxed architect or a registered professional engineer p�VMB�NG PERMIT ISSUING FEE S sV .
acting in my professional capncity(SeNion 705t,Bue• ,
iness and PrO�essions Code). � � TOTAI,FEE Q
Lie.or Reg.No. Uate Plan check epplicent � �
HOME OWNL•R-BUILDER DECLARATION Nam� � z� 6 7,3 A �
t hereby aiCrm that I am exempt from the Contractor's
Aad...: �. .. . .5
� License Law for the foilo��ng reason (Sec[ion.7o31.5,Busi- �Iry 7a1.No. " � �-- � • •'Z Q'rj� �
nrss and Professions Code): � -
� 1,as owner at the proDerty,am exclusively coniroctlng � - - ' • •2 Q 5�� ,
�»th licensed contractors to construct the projec[ .
(Section 7044,eusiness ana erofess�nns Code). � �- � O�L Z�7—B�2 �
CONSTRUCTTON LENDING AGGNCY - - � � -
1 hereby afCrm that there is a construction lending agency .
for the performence of the work for which this permi[ is � -
issued(Sec.J097,Civ.C.). .
Lender's Name .
Lender's Address
1
(certify that I have read this application and Stste that the . �
above intormalion is wrrect.1 agree to comply with ail County SEE REVERSB FOR EXPLANATORY LANGUAGE � - � ' �
ordM es and State laws regulating Plumbing, and herehy
aat ori� representatives of this County to enter upon the � . . � �
aUove- entioned propert!for inspect'n purposes.�'� � � .
� w
gn[ uf P rmit[ee Dat
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