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HomeMy WebLinkAbout1706A (10) 1VORKL•'RS'COAIPENSATIONDECLARATION �usuw APPLICATION FOR PLUMBING PERMIT � � � I hereby affirm that 1 have a'certificate oP conser�t to self cs ev(z-eo) � insure,or a certificate of Workers'Compensa[ion Insurance,or a certified copy thereof(Sec.3800,Lab.C.) � � � '' -. COUNTY OF LOS ANGELES BUIL�ING ANO SAFETY • Policy N��Company����V�r � � _ . � ' ' - � �Certified copy is hereby furnished. FOR APPLIC.4NT TO FILL IN(PRINT OR TYPE) ADDRESS S C9� '� � Certified copy is filed with t ounty b 'ldi g inspection NUM6Eq FIXTURE OR ITEM • FEE . . I � �t I.00ALITY �,r 7{� WATER CLOSET � Date�•71G2/.rr1 Applicent NEAREST I BATH TUB CROSS SL ��j CERTIFICATE OP EXEMPT[ON FROM WORKERS' • � COMYLNSATIONINSURANCE - SHOWER ' OWNER �C- . IAVATORY MAIL (This secHon need not be completed if the work involved � � n�oReSs .� Y ' � by the prnnit is Pot one hundred dotlars(SI00)o�less) . SINK GTY TEL.NO�ffrs'p O �� 1 certify that in the performence of the work for which ihis DISHWASHER V � � permit is issued,I shell not employ any pereon in eny manne[ CONTRACTOR�/ � so as to 6ecome su6ject to the WorAers'Compensatian Laws. CLOTHES WASHEq � � . � A��RESS s�� � O �. Dafe ADD�icant � SWIMMING POOL HECEPTOR CITY � 7E . V � NOTICE TO?IYYLICANT:If,after making this Cer[iPcate of �- �I Exemplion, you should become subject to the Workers' LAWN 3PRINKLER SVSTEM � STATE LIC. a fn { Compensation provisions of the Labor Code,you must forth• �ICENSE NO. S CLASS p Z '� with compiy with such provisions or this permit aha(1 be WATER HEATER — deemed revoked. . GAS SYSTEM OUTLETS ��STRIC/T NO. PRf�CESSE�eY � LICENSEDCONTRACTORSDECLARr+1TION . OUTLErSOVEP !� �/�-G��'J I hereby affirm that 1 am licensed under provisions of Chaprer 5 PER SY5TEM �� 9(commencing with Section 7000)of Division 3 ot the Busi- F�NA� VALIDATION I ness and Ro4ssions Code,and my ticenee is in full force and -tfetJ �t�JCJ DATE '� - ef(eet. �I�... ' �l �C. +.et�e., t/� . OS�/y /�f Fiwn� License Number Lia Class_fJ �� eV - Contracto�L�j[:L��—�"Date�/�_ f�� �7 � I am exempt from the licensing requiroments as[am'a PIBn cheCk fee �', j licensed architect or a registerod profeesional engineer PLUMBING PERMIT ISSUING FEE S �(� acting in my pmfesaional capacity(Section 7051, Bus- . iness and Professions Code). , TOTAL FEE 1 � � � Lic,or Reg.No. Dete ptan check applicent ��� � 1 /�4�� 217Q6A � HOME OWNER-BUILDER DLCLARATION Name � ' �(�f � � #... . .5 1 here6y affirm that 1 am exempt from ehe ContractoPs Adar.as /'�y�1� � � . License Law for the following rceson (Section 703L5,BUsi- City � Tel.Na. - /n�'"--� ����.� 2 5� . ness and PtoFessions Code): ��� � ' z � � � I,as owner of the property,am exclusively contracting �� . . . •�•��� 25�� . with iicensed contractors to construc[ tha project . 0�O P�S 2 � (Section 7044,Bwiness and Yrofpsiom Code). . .. � � , � CONSTRUCTION LENDINC AGENCY . � � � � I hereby affirm that there is a construction lending agency � � for the performance of ihe work for which this permit is - � . _ issued(Sec.3097,Civ.CJ• � � - Lender's Name- Lender's Address � � � 1 certify that I ha.•e read this application and sta[e that the � above information is correct.I agree to comply with alI County �SEE REV ERSE FOR LXYLANATORY LANGUAGE � - - � ordinanc and State aws regulating Ylumbing, and hereby . � ' authod� r rese ati es of this County lo enter upon the � a6ove- en ned ro rty Cor inspection purp xs� . . . - � � ignature Permittee Date '.. � � - . . _ , _ . _.__ . . ... - . - � ���.:.. 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