HomeMy WebLinkAbout1290A (6) WORKLRS'COMPENSATIONDECLARATION �sw�s�w f�
I hereb�affirm that I have Y certiCcate o��o�s�,< <o u�< <e.,,,=-.o, APPLICATION FOR PLUMBING PERMIT -�i
insure,or a cerlificate of Workers'Compensation In ura V
���(Sec.3800,Lab.C.) ��
COUNTY OF lOS ANGELES BUILDING AND SQFETY
Policr��Cu��(� .
� Ce tifie cnyy is er y urnis e 5/83 FOR APPLICANT TO FILL IN(PRINT OR TVPE)
BUILDING
A�ORESS
n Certified copy'ts filed wifh the caunty building inspection NUMBER FI%iUHE OR I7EM • FEE
`�� depattnl¢nt. �Q WqTER CLOSET - O LOCALITY
Dale Applicant NEAREST
4 BATHTUB O CROSSST. SUCISet CY�OSS�YI _ �
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCC Q SHOWER OWNER .
LAVATORV MAIL
(This section need not be completed if the work involved �� � ADDRESSfiZ9 COV��Ia BVfI
by the permit is for one hundred doliars(S1o0)or less.) 4 SINK � ctTv San D1mas re�.wo. 599-6864 p
I certity that in the perfnrmance of the work inr which this Q DISHWASHER a 0 V
permit is issued,1 shall not employ any person in any manner CONTRACTOR
so as to 6ecome subject to the Workers'Compensatioa Laws. 4 CLOTHES WASHER � �
A�DRESS 1040 l�f. SEcond St �
Date Applicant f
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT:lt,after making this Certificate af CITY P TEL.NO. W
Exemptinn, you should become SuFject to the Workers' � LAWN SPii1NKLER SVSTEM o-
Compensatlon provisions of ihe Labor Code,you must forth- STATE LI0. C�
with comply with such ptovisions or thi5 permit shall be WATER HEATER LICENSE NO. �42Z CLASS C-3() �
deemed rev�ked. 4 GAS SYSTEM 5 OUTLETS �4 O DISTRICT NO. PROCESSEO BV
LiCENSED CONTRACTORS DFCLARAT[ON OUTLETS OVER O
i herehy affirm that 1 am licensed under prnvisions of Chapter 5 PER SVSTEnn
9 (commencing with Section 7000)of Division 3 0(the Ausi• FInIAL VALIDATION
ness and Professions Code,and my license is in fult force and DATE � ��/�,3
effect.
Litense Number �422�4 LiC.Class C-36 FINAL
BY
c�R�i#��inePlumbin� nace 2-28-83
� I am exempt from the licensing requirements as I am a Plan check fee �
licensed architect or a registered professional engineer pLUMBING PERMIT ISSUING FEE S � 50 1 2 9.o A
acting in my professional capacity (Section 7051, Bus• �
inas and Professions Code). ' ' '
TOTAL FEE �� � � � �j
Lic,or Reg,No. Date Plan check applfcant �� . ' �,��2�O
110S1E OWNL•R-BUILDER DECLARATION Nama
+2G250=
U
i hereby affirm that I am ezempt trom the Contractor's Addreu �
I License Law for the following reason(Section.7031.5.Busi- ��ry Tel.No. U I.L%�ty 11 �
` ness and Profcsslons Code):
� 1,as o�vner of Ihe property,am ezclusively conttaeting �
with licensed contractors to cons[ruct ihe proJect � -
(Section 7044,Businexs and Protessions Code). .
CONSTRUCTION LENDING AGENCY ' . . .
I hereby affrm thaf there is a construction lending agency
for fhe pertormance of lhe work Por w�hich Ihis permit is ;
issued(Sec.3097,Civ.C.). �
Lender's Name '
LendeNs Address
I certify I hav read this npplication and state that ihe �
above inf ion Is nrrect.1 a ompiy with all County SCti REVERSF,i�OR ERPLANATORY LANCUAGE � -
ordinanc s n tat law eguiating Piumbing, and hereby .
authori� r r nt ot this County to enter upon the .
above- o r p r inspection pur oses.
� ,
S� n ure o Permittee Date
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