HomeMy WebLinkAbout1675A (10) � . ---__ _�.._.._ _...- .. _ . ,
WORKERS'COMPENSATIONDECLARA7ION nasas� �
I hereby affirm �na� 1 have scertificate o��o�5�f�o self �E.,�,=..o,. APPLICATION FOR �� LUMBING PERMIT.� �j
insure,or a certificate ot Workers'Compensatton Insurance,or � �
/�a certifled copy thereof(Sec.3800,Lab. .) � - Ll
�¢Y^u�9/77� COUNTYOFLOSANGELES BUILDINGANDSAFETY - �
O�ICyN6 mDany
�ertified capy is herehy furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUIL�ING � �
ADDflESS
� Certi£ed copy is filed with he c nty huil ' g i c"on �BEA .FIXNRE OR ITEM � FEE
�i a m � LOCALITY +�
Date_.���PPlicent WATER CLOSET � NEAREST
BATH TUB CROSS ST. . �
CERTIFICATEOFF.XEM ONF OMWORKGRS'
COMPENSATI INSIfRANCL SHOWER OWNER � .
MAI L
(This SeCt1o� need pOt be ComPleted 1f fhe wOrk InvolvCd LAVATORY � Q� ADDRESS � a
6y the permit is for o�hundred dollars (5100) or IeuJ SINK � � � �
D� CITV TEL.NO. U
I ttrtity that in the performance of the work tor which this DISHWASHER � '
permit is issund,I shall nqt employ any person in any Manner CONTRACTOR �
so as to become subjett to ihe Workera'Compensation Laws. CLOTHES WASHER V �
ADDRESS
Da[e � ApP���ant 3WIMMING POOL RECEP70R W
NOTICE TO APPLICANT:If,atter making fhis Certificete of CITY TEL O. °" I
Exemption, Y�� should become subject to the Wnrkers' LAWNSPqINKLEFSVSTEM _ '
Compensation pror-isions ot tlie Lahor Code,you must forth- STATE LIC. 7
with comply with such provisions or this permit shell be WA7ER HEATER LICENSE NO.� CLA55 C— 7
deemed revoked. DISTRICT NO. PR ESSED 9V
GASSVSTEM OUTLETS
LiCENSED CONTRACTORS DF;CLARATION OUTLETS OV ER lO �`�
1 hereby a(firm thal 1 am licensed under provisions of Chapter 5 PER SYSTEM � ..
9(commencing with Section 7000)of Division 3 of the Busi- � � � FINAL � � VALIDATION
ness snd R�fessions Code,and my license is in full force and DATE {'� p-'�' �,,,! �
effect. � � � ,
— �'C,_ �� FINAL . r�r� I i
License Number Lic.Cless '�
Contr to Date
� BY � �r^+' . ;
� I am exempt from the licensing requirements as I am a Plan ched(fee . I
licenxd architec� or a registered professionai engincer pLUMBING PERMIT ISSUING FEE S I
- acting in my pmfessionol capacity(Sectan 7051, 8us- Q
iness and Professions C�de). TOTAL FEE �' (� �l(}
I.ic.or Reg.Nv. Date Plan check applicant �
a16Z5A
HOME OWNBR-BUILDER DECLARAT(ON Name � . : - ,
�. . . . .5
1 hereby affirm that 1 am ezempt from the Contractor's Address �
Li=cr,se Law:or Ihe foiiowing rcuson (Section.7031.5,Buai• CitY � Tel.No. � _ �'� �z p 5� .
ness and Professions Code): + • •,�Q,5 O U
� I,as owner of the property,am exclusively contracting � . - - � �- � .
with liCensed conlractors to construct the yrojet! 0'Z 2 6—$'� �
(Section 7044,Business and Professions Code). . � ,
CONSTRUCTION LENDING AGi[NCY ' ' . . . � � � - . �
I hereby affirm that there is a construction lending agency ' �
for the performance of the work for which this permit is '
issued(Sec.3097,Civ.CJ. � .
I
Lender's Name .
Lender's Address
1 cer�ity that 1 h�ve read thi5 application and State ihat the . �
above infnrmation is correct.I ogree to cnmply with all County SF.E REVERSIi fiOR EXPI.ANATORY I,ANCUAGE
ordinances and State �aws regulaling Piumbing, and hereby
auth .e epresentatives of thia County to enter upon the
atiove-me ioned propert or i specti n purposes. - �
a - z . a
ture t Permittee Dat
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