HomeMy WebLinkAbout0846A woRKERs•coMPeNsarioNoeanRarioN APPLICATION FOR PLUMBING PERMIT � a
I here6y aFfirm ihot I have a certificate of mnsent to self 76A667A �
insure, or q certifimfe of Workers'Compensafion Insurance, CE 8U(REV.70/BI)
o�o ce�t�t�ed o�y rhereof(Sec. 3800, _b.Ct). � COUNTY OF LOS ANGELES BUILDING AND SAPETY
P❑ol�icy No�_.�.J °t;ompany ' �'� .
Ceriified mpy is hereby fumishe .
Fph APPUCANT TO FILL IN(PRINT OR iYPE) bUIIDING •
� Certified copy is flled with the co�nty building inspec- P.DDRE55 —� �
tion department. NUMBER FIXTURE OR ITEM �' FEE �
LOCALITV[�
WATER CLOSET /} �'---�i
Date Applicanl ___. �`Q NEAREST
CERTlFlCATE OF EXEMPTION FROM WORKERS' BA7H 7UB /�h CNOSS ST. -
COMPENSATION INSURANCE -- � �f OWNER °
SHOwER �O ..
(This section need not 6e completed if the work involved by ��,,� �
the permit is lor one hundred dollars(S10Q)or less.) LqVAtORv AD�Re55 � _— . i
I certi4y that in the performonce of Ihe work for which this �
permit is issued,1 shall not employ any person in�ny monne� SINK � CITY "�. 7F.L NO.
so as to become subject to the Workers'Compensotion Laws. DISHWASHER �
COMRACTOR
Dafe Applicpnt CLOTHES WASHER ADDRE55
NOTICE 70 APPLICANT: If, after makEng ihis Certificate of �.� c�,� •
Ezemption, you should 6ecome subject ro the Workers� SWIMMINGPCOLRECEPTOR CITY TEL.NO.��
Compensatlan provisions of the tabor Code,you must forth- �nwN SVRiNK�ea SYStenn
with comply wifh such provisions or this permit sholl be STATE LIC.
deemed revoked. WATER NEATER LICENSE NO. CLA55 �
LICENSED CONTRACTORS DECIARATiON DISTRIQ NO. ��PROCES55$EEED BY
I hereby affirm thar I am licensed under provisione of Chapter 9 GAS SVSie1�n Ouite75 � ��..�/
/�.
(commencing wifh Section 7000)of Division 3 of the Business pUTlf.TSOVFR
and Professions Code,and my license is in foll fo:ce and effed. 5 PER SVSTEM i _ p�ryAL ` ^ �_g�� VALIDATION a
} G �� DATE , ��
License Number S����� Lic Class � o
FlNAL O,
Contronor�iL�1J42�—Date ������7 — 6Y O �
❑ I am exempt under Sec . � �
B.BP.C.for this reason ► . � ;
Plan check fee
�08G,6A n' �
���e� PLUMBING PERMIT ISSUING FEE ,S � �
Signature $ �� �� - '�•• e m •5 Z{
TOTAI FEE �;1 7
Plon check applicant
� � o ♦QO,J��
SWGLE PAMILY � �
NOME OWNER-BUILDER DECIARATION Nome m ' `�'��J��-'
�
1 hereb offirm that I am exem t from the CoMracior's License �
Law for the following reason(Section 7031.5, Business and Address � . �„_ u�,� L�—�v 7 -�
f
Professions Code): Ci�y Tel.No. �
❑ I, as owner of the property, will dv ihe work and the - . i
slrocture is not intended or offered fo�sale (Section , �
7Q44,6usines=_and Professions Code).
CONSTRUCTION LENDWG AGENCY �
I hereby affirm thai ihere is a consfruction Iending agency for
ihe performance of ihe work for which this permit is issued E
(Sec.3097,Civ.C.}. �
Lender's Name -�
i
Lender's Address �.
I certify tha�I have read this appli<nfion ond sta+e that ihe � �
a6ove informotion is mrred.I agree fo mmply with all County �.
ordinonces and State laws reg�lating Plumbing,ond hereby � .
outhorim representolives of this County to ente! upon �he
above-m on p� e.�y for Inspec�ion purposes- -
SEE REVERSE FOR EXPLANATORY LANGUAGE
�-\�-�
. Signature of Permiuee Date .
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