HomeMy WebLinkAbout1674A (10) ��ORKERS'COMPGNSATIONDECLARATION ������- , APPLICATION FOR PLUMBING PERMIT �j}
I hereby slfrm that I have a•certiCcete oP consent to self cs�ev(z-so
insure,or a certificate of Workers'Compensation Insurance,or � � l,
a cert���cop�iJ�e f(Se 3800,Lab .) .
� t� y f�7 's�' COUNTY OF LOS ANGEIES BUILDING AND SAFETY
Pol ey No.' Company � '
��CertiCeJ copy is hereby furnished. FOR APPLIC.4NTT0 FILL IN(PRINT OR TVPE) 6UILDING
❑ ADORESS �-J�� - .�}-{
Certified copy is filed with the co nty 6uiidi ina c ian NUMBEP FI%TURE OR ITEM • FEE
�!e�ar/t�p��eq/t.�f LOCALITY ��C//�j
Date_�d / �ApPlicant�� WATEF CLOSET U� NEAREST
BATH TUB CRO55 ST. �
CF.RTIF[CATE OF EXEMP �ON F M WORKFRS'
COMPENSA71 INSURANCE SHOWER OWNER . �
LAVATORY - MAIL .
(This BecNon need not be completed if the work involved �� ADORESS � � } -
by the permit is for one hundced dollazs (f100)or less.) �
SINK .� p D CITV TEL.NO. p
I rertity that in the performance of the work for which this DISHWaSHER " V -
permit is issued,1 shall not employ any person in any menner CONTRACTOR �
so as to become subjeet to the Workers'Compensation Laws. CLOTHES WASHER � '
Date Applicant ADDRESS ��'�- ����,y O
SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT:IT,after making this Certlficate ot � CITV � TEL.NO. _f�6 t' tt� �
ExeTD��on, yoU Should become 5uhject to the W�rker5' LAWN SPRINKLER SYSTEM STATE —f r LIC. �+ / U �
Compnnaalion provisions of the Labor Code,you must forth• yyqTER HEATER LICENSE NO. 3/ SJ � CLASS 1..� �lp Z
with tomply with such provisions or this permit shall be — ,
deemed revoked. GAS SYSTEM OVTLETS DISTRICT NO. PROCESSED BY .
//
L1CF.NSF,UCONTRACTORSDECLAR.ITION - OUTLETSOVER l0 �j
l�herehy eff'vm thet I am licensed under provisions of Chapter 5 PER SYSTEM . ._ . . . . , . �
9(tommencing with Sec[ion 7000)of Divisinn J of Ihe Busi•- - �
ness and Professinns Code,and my license is in[ull force and DATE �C' "� � �'�' VALIDATION
effect.
FINAL ,�
Licentt mber 7 I�iaClass C` 3 G � - BY '�� .
Contr te ��e �
� 1 am ezempt hom the i nsing requirements as I am a Plan check fee � ,
licenud architect or a registered professional engineer pLUM81NG PERMIT ISSVING FEE$
acting in my profe55ional cepatity (Section 7051, Bus- �
inesa and Yrofessions Code). TOTAL FEE � �Q -�1 6 7.4 p �
Lic,orReg.No. Dete Plancheckapplicant �;• •�• • •�j
IiOMF.OWNER•BUILDER DECLARATION Name I • •3 2 5 0
1 hereby a[firm that I am exempt from ihe Contnctor's Adtlrasf . •�• •3 2�u� .
LICCIISC Law for�he foilowing reason(Seclion.7031.5,Busi• Citv " � Tel.No. - � � �
ness and Protessions Code): �2 L 6�$2
� 1,as owner of the properfy,am exclusiveiy contracting � - �
with Iicensed contractors to cons[ruct the project
(Section 7040,Business and Professions Code). �� � �
CONSTRUCTION LENDING AGENCY . . � � �
i hereby a(tirm Ihat there I5 a constmttion lending agency
for the performance of the work for ahich this permif is .
issued(Sec.3099,Civ.C.)• � ,
Lender's Name � .
Lender's Addrss
I certify that 1 have read tMs application and state Ihat the � �
above information is correct.I o6ree ro comply with sll CouMy SEE RF.V ERSE FOR EXPLANATORY LANGIIAGE � � � �
ordinances_and State laws re6ulating 1'lumbing,and hereby
authorize r resentatives of this Coun[y to enter upon the
above-ment' ned prope ty f ns tlo �urposes. _
�� 8��
�g t e�t rmittee Date '
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