HomeMy WebLinkAbout1036A (5) R'ORKERS'COMPENSATIONDECLARATION _ xwuvw /'� .
I hereby affirm �ha� [ have a'cerNficate of�o��<<o��f �e.���=-.o, APPL�ICATION FOR PLUMBING PERMIT -�i -
'� insure,or a certificate of Workers'Compensation Inaurance,or � i�
;I a certified copy thereof(Sec.3800,La�b.c.�� COUNTY OF lOS ANGEIES • � BUILDING AND SAFETY
� Policy No�Company -� � � �
� � Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN(PRINT OH TYPE) BUILOING
�' � NUM9ER FI%TURE OH ITEM � FEE ApDRE33 j�') �' ,
r �ertified copy is fled with the counry bWiding inspeaion .
depar.menL - � � LOCA(.ITV r
Ig Date Applicant � N�ATEp CLOSET NEAREST . �
' BATH TUB CROSS SL �
CERTIF[CATE OF EJCEMPTION FROM WORKERS'
COMPENSATION INSURANCG SMOWER . � OWNER � � �
� �� LAVATORY MAIL �� � . �
(This section need not be compiMed if the work involveA qo�nEss �Q!'YI }
I�� by the permit is for one hundred dotlars (5100) or leu.) . .
,, � SINK � dTY TEL. O. �
y I certiry that in the performance of the work for which this DIgHWASHER U
,. permit k issued,1 shall not empioy any person In any manne[ " CON7RACTOH � � .
� so as[o become subject to the Workers'Compensation Laws. ClO7HE3 WA3HER I �
� ADDFESS � lO/� �� �.,� �
; Oate Appficant gWIMMING POOL RECEPTOR (~j
� NOTICE TO APPLICANT:If,aftec making this Certificate of CITV rn�s TEL.NO, �
Exemption, you should become su6fcct to the 14'otkers' LAWN SPHINKLER SYSTEM ,f'1 � �+ o-
�Compensetion provisions ot the Labor Code,you must forth- yyq7Ep HEATER LICENSE NO. ����J� CIASS LJ`� Z
� with compty with such provisions or this permit shall be . —
deemed revoked. OI6TRICT NO. Pq CESSED BY
GAS SYSTEM -OUTLETS
LICENSED CONTRACTORS DECLARATION OUTLETS OVER - �� Q„`�..(,J
� 1 hereby atfirm that 1 am licensed under provisions oC Chapter 5 PER SYSTEM
� 9(commencing with Section 1000)of Division 3 of the Busi� � y ,y � �� FINAI VALIDATION��
ness and Professions Code,and my license is In futl torce and - -/ � !7�[�fl /V..[ i d DA7E J a,`-/7���
i eBnct.� � ` �
� ����/� FINA
� License Numberld.lS� Lia Cless� BY�
Contractor�.—.L�L'�rn� Dete - �
'� I am ezempt from the licensing requirements as[am h Plan check fee . ,
l � licensed nrchitect or a rag�stered profeasional engineer pLUMBING PERMIT ISSUING FEE$ � �jQ �
acting in my protessional caDacity (Section 705t, Bus- n
iness and Profesaions Code). TOTAL FEE /��v � Z
�, Lic,or Reg.No. Date Plan chxk appliteat ' ' �� O.A b A
HOh1EOWNER-BUILDERDECLARATION Nama . . . #' �,�'' �5
� 1 hereby affirm that I am exempt trom the Contractor's p'dd�°u � � • �� Z rJ�
f License Law for the fotlowin reason Section 7031.5.Ausi- �
8 � City � - Tel.No.
� ncss and Protessions Code): �, � �-• •1 2 rj.Q v
�� � I,as ownet of the proDerty,am oxdusively contracting � . � � . .� I,L�6 y 8,�
with licensed contrac[ors to cons[ruct the project .
(Section 7044,Business and Professions Code). � . . . � � �
� CONSTRUCTtON LEN�ING AG6NCY ' . � �
I hereby affirm that the[e is a construction lending agency � �
tor the performance of the wo�k for which this permit ts � _ �
" issued(Sec.3097,Civ.CJ. , - ,
Lender's Name . �
� Lender's Addmss �
' I certify that I have road this applicaHon nnd state that the _ � � � �
above inFormation is correct.I agroe to comply with nll County SEF,REV ERSE POk LXPLANATORY LANGUpGE � � -� � � �
ordinantts a�d State laws regui�ting Plumb(ng,and hereby � - ' �
� autharize representatives of this County q enter upon the � . . �
� above �oned prop ty c' �poaes. �
; ' 2 �-�'�
,, ature of Ye i t Date - �
__ _ _ _ _ _
� APPROVALS DATE INSPECTORSS�GNATURE - INSPECTOR'SNOTES � � OIVNER•BUILDEP DECLARATIOiV
UNDERSLABWORK ' " _ � � � . � �
� ROUGH PLUMBING � � �• 1 hcreby affirm thal I am exempt f[om thc Contractor's
Liccnsc�Law feir�'tBe'following ceasod(Seclion 7031.5, i
'', GA5 PIPING�� —� -• � � � - - - � ��- � � ' Rirsi�less Ond Projession}' CodeJ: An}• ctry or rourrty i
�� GAS vENT �, � � - � � . . . � .. . . ' . �elrrcl� requires o pennit to construct. alter, improre, �
HO�WATER HEATER � dr:ltl0llSll,O7'rCj7ai/UI!}'SlntC7GIP,p/JOr tn It5 iT.SucitCC, '
' , � � also irquirer tlre appficanf jor such peruril 10 file a' ;
PLl/M�ING FIXTURES- � - ��� ' ' ' '
, sig+ied smtemeir� d:c� lie is (icenred pursumrf Jo the �
g GAS 7�ST . . p�orisions of t!re Coulroctor's'Licerlte La+r(C/+apter 9
. UTILITY CO.NOTVFIEO - . �COfriMfllCLtg x�i7h Secrion 7000/ oJ Dirision 3 of ti+e �
. _ . . � - .. . ._ . � Batsiness mtd Projrssron.r CoJe/ or flmt Gr ir exerupt
tlterefrmrt and the hasis for tlie alfeged exemp�ron.Arr}'
' F�nlaL _ _ L'�ytv�t, p�t �Zpyi.� '�� � ' -� - riolatimt of Sec�ion 7031.5 by mq'apPlicant jora pernrrt
� ,, subl�cU tlte applicmtt to a eit�i7 Penahy of rrot rr�ore d�a�r
�� - � � � � � - fire hundred dnllars(SSOOJ.: -
INDUSTRIAL '� , , . �. � � ❑I,as o�aner of the property�cill do the�voik,�and
� WASTE.APPROVAL.' - '�- - -
�� . � [he structure is not intended or offrred for safc. �
.. • ' � . , - ' . - . /Sec. 7044, f,uvincss arrd Prnjessiwu Code: Thc'Coir-
, -- • - . � .� � - � � lractnr} License Lan�docr irot applp ro mr�oioner of
i .. .� �. �. .�� . . . ... . � . � . . . . . . . properp'.�elio Guilds or irnprores tltcrcat,mtd udto does
�i . _ �. , . . . . . sud2 work hierucll Prorrded that ntcL iittProrcr�re�irs
. � . � . � , �� '- . . . ¢rc vrot irticnJed or offcred Jor so1e. Ij, lmwcrcr, die
� . � - . � � bullding or intp�orcnten� ir so(d K•ithiu one }•ear af
� ' ��..\ . � . cornpletion. !he airuerbuilder wrl! hm�e die Gurdeit
; ' . .. �� � . . __ . ._ . - .. . � of proring flm� !rc did no� buRd or improvc fo�Nre
� � ' - � purposc of sale./ � �
1'- i:' �. ' I am exempt under Sec. ,
`B fi'P.C.for this reason
Aate
O�rner
r,azor :•. _
� ., • � •INSPECTOR'SNOTES . �
c:�sr • • i
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