HomeMy WebLinkAbout1676A (10) WORKERS'COMPENSATION DECLARATION 'l1A��fA �
I here6y e�r�m that 1 have a'cer�iflcate of consent to 5e�f �Ee„�=..o� A-PPLICATION FOR PLUMBING PERMIT .
insure,ot a certifcate of Workers'Compensatlon Insurance,or . • -
�ertiFied copy thereof(Sec.3800,Lab.C.) ,
i(_�yyq���—s __�Q�'�,�—�/ � COUNTYOF LOS ANGELES BUILDiNG ANOSAFETY
o�cy o. Company_/R'�'�_ ' � '�'t� � .
�tertified copy is hereby furnis�d. - FOR APPLICANT TO FILL IN(PRINT OR TYPE) qDIDRE55 7 J� /V�yy
� CertifieS copy is flied with�the cou ty buiidin in BER FIXTURE OR ITEM � FEE
�iep m t WATER CLOSET � �OCALITY
Date pplicant NEAREST .
BATH TUB CROSS ST. . �
C RTIFICATE OF EJCEMPT N FR WORKERS'
COMPENSATIO NSURANCE SHOWER ' OWNER �
1 LAVATORY MAIL . }
(This sectian need not be completed if the work invohed UU aovRESS a
�by the permit is for one hundred dotlars (SI00)or leu.) SINK �
� �O CITV TEL.NO. U�
'1 certity that in the performance of ihe work for which this DISHWASHER CONTRACTOR �
ermit u issued,f shall not employ any person in any manner J-�i
o at to 6etome su6jett to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS .
Date ADP��cant SWIMMING POOL RECEPTOR CITY .NO. r�p'j
NOTICE TO APPLICANT:If,aker making thii Certificate oF
Exemption, you sbould become subjec� tn the Workers' LAWN SPRINKIER SYSTEM � STATE LIC. Z
Compencatfan provisions of tF.e Ls6or Code,you must torlL• yyp7ER HEATER LICENSE NO.� CLASS ��
with comply with such provisions or thla�permit shali be
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PR CESSED BY
4iCGN5GD CONTRACTORS DECI.ARATION OUTLETS OVER I O ��,�,d�t�
I hereby afCirm lhat I am licensed under prnvisions of Chapter 5 PER SVSTEM .
9 (commencing with Section 7000)nC Divuion 7 0(the Busi- � ��� � - � FINAL � VALIDATION �
ness and Professlons Code,and my license is in full force and �ATE � . ,
effect. ' - �
� Lic se Number � Uc.�Clasa �� � � BY AL �/�� ` ,
,Date �
� I am exempt from the nsing re uireme ts as I am a Plan check fee � �
licensed arcbitect or a re¢iatered professionai engineer pLUM81NG PERMIT�SSUING FEE 5 �
acting in my professional capacity(Section 7051,Hus- �
iness and Professions Cnde). TOTAL FEE 3� (J
Lic.or Reg.No. Dale Plan check appiicant
IiOME OWNER-BUILDER UECLARpT10N Nama
I here6y affirm that I am exempt from the Contrsctor's Add�ess t'�„� �J 7,�n
l.irenie Law(or the fo!b�t�ing rcason(Scction.^D313,Eusi• City � TN.No. � � � � �
nasandProfessionsCode): N�� • • �.�5
� i,as owner of the property,am exdusively conttactinR
with licensed mntractors to construct the project . �.• •3 2 5 0
(Section 7044,Husiness and Professions Code). � . � � � �
• • •3250�
CONSTRUCTION LENPING AGENCY � �
1 hereby affirm that there is a consiruetion lending agency � O Z Z 6�a P '
for the performance of the work for which this.permit is . .
issued(Sec.3097,Civ.C.). .
Lender's Name � "
Lender's Address �
i certify Ihat I have read ihis application and state that the � .
above infarmation is correct I agree to camply u•ith all County � SLE REVERSE FOR IiXPLANATORY LANGUACE �
ordin es and State law�s regulating Plumbing,�and hereby
au oriz reDreseMatives of this Count to enler upon the
ove-m ntianed pr�w ert f r i specti purposes. . - � ..�
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