HomeMy WebLinkAbout1175A (5) --�
WORKERS'COMPENSATIONDECLARATION �••••,• � APPLICATION FOR��PLUMBING PERMIT �
I hereby affirm thal I have a cerliFicate of conserit to selt ea n�I2-�D) ��
insure,or a certificate of Workers'Compensation Insurance,or
a certi�ed�opgthereof(Sec.3800,Lab.C.) . � � .
r�u'.���• y� C_ COUNTY OF LOS ANGELES BUILDING AND SAFEtY
Policy No.�L�ccbs�Company�.�}1�Tu�-/1�A1S.�QU((� � . . . .
'�Cettified copy is hereby furnished. FOR APPLICANT TO FILL IN(PHINT OR TVPE) BUILDIN(3 ��
ADDRESS
� Certified copy B filed with the county building inapection NUMBEH FI%TURE OR ITEM • FEE �
/ LOCAUTV
OateC��Applican WATER CLOSET �
NEAREST
. � BATH TUB CROSS ST.
CERTIPICATE OF EXEMPTION FROM WORKER . OWNER
� COMPENSATfON INSURANCE SHOWER
LAVATORY MAIL �� "'- ` } '
(This eection need not be completed it the wark involved nooAEss �•�w �
by the pemtit is fm one hundred dotlars (5100)o[IESS.) � SINK ��
CITY TEL.NO
I certi(y ihet in ihe performence of the work for which fhis DISHWASHER ' � �
permit is issued,1 shall not employ any person in any manner CONTRACTOR ,
so as to become subject to the Workers'Compensation Lawa. CLOTHES WASHER ADDRESS C � U �
Dete Applicant gWIMMiNG POOL HECEPTOR ��� a
NOTICF,TO APYLICAN7:If,after making this Certircate nf CITY TEI.NO. y
LAWN S�RINKLEH SYSTEM Z
Exemptinn, you should become subject to the Workers' � STA7E LI0. L1. L
Compensation provisions of tbe Labor Code,you must forth• yyqTER HEATER � LICENSE NO CLASS —<I
with compiy with such provisions.or this permit shall be DISTRICT NO. pROC�E5SE0 BY
deemedrevoked. � GASSVSTEM OVTLETS �///�
� LICENSFDCONTRACTORSDECLARATION OUTLETSOVER �0 v���f�� .
1 hereby affirm that I am licensed under provisions of ChaD�er ' 5 P R SVSTEM �
�� 9 (commencina with$ecNon 7000)of Divisian 3 of the 8us6 y / FINAL /) ^-� �/j VALIDATION
ness and Rofessions Code,and my ticense is in full force and .�Gl. +�� O� DA7E � / �(„
effect. . . . .
�_ _� FINA
License Numbe� Lic.Cless eY
�/ � �
Contracto=IY����F Date��
� 1 am exempt from�the licensing requirements as I em a Plan check fee .
flcensed architect or a registered professional engineer pLUMB�NG PERMIT ISSUING FEE 5 � �
� aUin6 in�my profeasional capatitY (Section 7051, Bus• "' . •
incxs and Rofessions Code). TOTAL FEE � l� ,
Lic.ot Reg.No. �Date Plan check apPlfcant �� �7 5 A
HOME OWNER�BUILDER DGCLARATION Nama � �� �-� ���5 � �
Addrees
I hereby afCvm that I am ezempt from the CoatractoPs '� •� � Z�Q . �
License Law Ior the following reason (Section 7031.5.Busi- Clty Tel.No. � � .
ness and Rofessions Code): �
� 1,as owner of the DroDertY,am exciusively contnetinQ . . •�� ' � 2 5�F��'
with licensed contractors to construct the pmject . � �I Z'.�� "S� '
(Sectlon 7044,Buainess and Professions Code). � . ... . � � ��,
CONSTRUCTfON LENDING AGENCY . . . � � � �.
I hereby affirm ihet there is a wnstruciion lending agenty .
for the pertormance of the work fo� K'hich this permit is . �
issued(Sec.3097,Civ.C.). . - �
LendePs Name � � � - �
Lender's Address �
I certify that 1 have read this appiica�ion and state thet the � � � :
above infarmation is correct.I aaree to comply with all County SF.F.REVCRSE FOR EXPLANATORY LANGUAGE -
ordlnances ond State laws regulating Plumbing, and here6y � . '
authorize representatives of this County to enter upon the . ,
abov-mentloned properry for i ction urposes. � � '
n� ,, �� p �(1�5'�[_1� /��3/��/
Bnature of Permit e Date
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