HomeMy WebLinkAbout1598A (9) � `� �� WORKERS'COMPENSATIONDECLARA710N APPLICATION FOR Pl.UMBINC� PEI�II�IT � '
I here6y affirm ihaf I hcive o certificate ot consent to self 76A667A �
,'„inwre,cs a cerfificate of Workers'Compensation Insuronce, CE 817(REV.10/81? . . -
or o certi fie d mpy t hereo f�Se�.3 8 00,�a 6.C.1 COUNTY OF LOS ANGELES BUILDING ANP SAFETY
P❑olicy N Co�mpany. . . . ..
Certtfied Copy s hereby_fumi5hed. BUILDING '7 ` f�[/
�- � �� FpR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS � J//��'I✓ � WL�(,`3
Ce t f ed copy i f led -Ih ihe couniy bu Id ng�insper ?
tio depaetrt enf � NUMBFR FIXTURE OR ITEM @ FEE �OLALITY
Dafe -� Appl�coni WATER CI.OSE� NEARES�
-`CERTIFICATE OF E%EMPTIQN FRO(v1 WORKERS BATH TUB CROSS 57. . �
� -� - - COMPENSATION�IN3URANCE. OWNER `� : ��_�
� (?his secfion need nat be c3mpleted i!lhe�wark{nvolvad�y SHOWER _
- Ihe permiT ia for ane hundred doilars-(�IOb)oFfess.J �AVaTORv MA�� �
A�ORF55,. r'?;J'p^+
I�certify that in the performance of ihe work foi which ihis a
permif is issued,I Shdll no1 employ ony pe�son in any-manner SINK CITY TEL.NO.y���ji��^��
��o
- so as f�e�o me�ubject.to the Workers--Compensdtion lnws. DISHWASHER � - �y
� CONTRACTOR �a G.y �
rL{�
DaT `r - pplicant "�`�'� CLOiHES WASHER ��«, + - �"
- A�DRF.SS ,,,, -- a
NO � E T APPLICANT:�If,-after making this C�rtificme of SW�MMiNGPootRECEPTOR �g � � �
, Exemption, you shou�d�.6ecome��subject fo-�he- Workers' CITV .� �P-� TEL.NO���`"�
Compensation provisions of�the.labor Cbde,-you mVs�forYh- LAWNSPRINKLERSYSTEM �p`-��'"yrI�
. .with comply wifh s�dch..provisions-�or this�permit shall be � - - SCENSE NO. �J�°,f� .C ASS �
deemad revoked. - -- WATER HEATER
LIEENSED CONTRACTORS qECLARATION � DISTRICT NO. ROCESSED BY
- I hereby aRirm that I om licensed undei.provisions of Chap�er 9 -� GAS SVSTEM OU7tE75 \�
(rommencing with SectionJ000).of Division.3 of fhe Business OUTLEf50VER �
� and Professions Code,6nd my license is in fu�l force and effed. 5 PER SYSTEM PINAL
p �ATE V�nLIDA710N �;
.� License Number � �`6 ��� Lic.Class���� � ��- � � � "�� p�y�p �'
a� � �. . . � BY A� � '"�(s�✓yd s O7� �
r
Contracior � Date_ �
I ❑ _. ,�.�... - .__. . . . �
I pm exempt onder Sec. � _ _ �
� 0.&P.C.for this reason ._. � � � 4-0
Plan check fee �
. . . __Date: p�UMBING PERMIT ISSUING FEE$ �� y
Signafure � _ �
� TOTAL FEE.
- Plan ch�eck applicant
- SINGLE FAMILY � — --
HOME OWNER-BUILDER DECLA2AIION Name �
I here6y affirm that I am exemp�from the Conirador's License Address �
Law far the following reason(Section 703I.5, Bwiness ond _ _,,� �4 F��
Professions Code): City Tel.No.
❑ I,as owner of ihe proper�y,will do the work ond fhe {;��"' �' `� ''��
strudure is not intended or offered for sale (Section
7044,Business dnd Professions Code). �� ''�'�'i��,J�
CONSTRUCTION LENDING AGENCV . � c "s:
I hereby affirm ihot there is mnslruciion lending agency for ' ""�' ���°�'`?G�
the performance of the work for which this permit is issued ����.���
. (Sec.3097,Civ.C.).
� Lender's Name '
Lander's Address � � � -
I certify thot I hove read this applica+ion and state that the � �
above information is correct.I agree b comply with oll County �
� ordinonces and State lows regulafing Plumbing,and hereby
outhori>e representotives nf this Counfy to enter upon the � �
above-menfioned properly for insFectior purpases. � � �
,� SEE REVERSE FOR EXPCANATORY IANGUAGE
�
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