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HomeMy WebLinkAbout1369A (7) ,WORKERS'COMPENSATfONDECIARATION /�ppLICATION FOR PLUMBING PERMIT � � I hereby,ofFirm thal I have a certifica�e of consent to self �gpgg7p . insure,or a certificote oi Workers'Compensotion Insuronce, CE 817(FEV.8/88) � - - � � � �- or o cer�ified copy�hereof Sec.3800,lob.C.) � . ` � � � ❑ Y '� 9� -�� Y 5.����na COUNTY OF LOS ANGELES DEPT:OF PUBLIC�WORKS Polic No. Com n � - �.�. ' �Ceriified copy is hereby furniahed. � � � � ' FOR APVLIUNT TO FIL�IN(PRINT OR TYPE) B���q�' . � Ceriified topy is filad wilh!he county building inspeo- ADDRE55 tion deporlmenl. . NUMBER FIXTURE OR ITEM � FEE pote���p ioca�m s�L�AppliSant C P WATERfLOSET - - NEARfST � � CERTIFICATE OF EXEMPTION FROM WORKERS' B.4TH TUB ��ST�� . COMPENSATION INSURANCE OWniER � - � � - .(Thfs wdton nNd no1 M compbt�d li ih�wo�k inrolv�d by SHOWER ' . ' , th� ermit i�for on�hvndrad dollan i100 er b�■. '�'°'�� P I � � IAVATORY O� App�� . I carti(y thuf in the performaace of Ihe wo�k for whith Ihis SiNK CI7V C ' � permi�is issued,I sholl not employ ony per:on in any manner � �; . so os fo betome sobjad to Ihe Workers'Compenwtion Lawz ' DISHWASHER ��R�� , - ��te sppliconl � ttOTHESWASHER AODRESS ` � jICE TO APPLICANT: I(, after moking fhis Certifimte of � � ...mpiion,.you,should bemme subjeU to the.Workers' SWIMMINGPOOLRECEMOR Compenwlion provisions of Ihe La6or Code,you musl forth• CITY � TEL,hq 3 with com t 'th such rovisions or ihis �mif shall be �AWNSPRINKLERSYSTEM P Y P Pe STAiE IIC. C deemed revoked. WATFR HEATFR ���N��- � M55 � ' � IICENSED CONTRACTORS DECLARATION . o�Srn�CT MO. wtOCE55ED BY � I hereby aHirm�hat I um licensed under provisions of CMp�er 9 GAS SVSTEM OURE75 '� (commencing wi�h$edian 7000)of Division 3 of the Buziness WTIETSOVFR O ���Qn � ond Professioas Code,oed my license is in ful I face ond effed, 5 vett SvSieM FINAL �/��/�� VALIDATION O DATE y Ucense Number Lit.Cbss � � � � FINAL �n� p Conlroctor C�e te�(-�-R� BY Q/G �... U ❑ � I om ezempr�nder$ec. N . B.BP.C.for Ihis reason plan check fee � � ► ? � � �18� . PLUMBING PERMIT ISSUIMG FEE f . `� J�9 A Signo�ure " � TOTAL FEE �� � � � �J . Plon thetk applicanl � = �7�i�J� SINGtE FAMILY �T l HOME OWNER-BUILDER DECLARATION � � Name- . ° a '�J(a 5 0 {wby nHirm rhn�I om e�wmpl from the Contractor'a licenae y�o�ess " . � � - -- ' � � �����,J, /i v A 7 low for�he foliowing reason(Sec�ion 7Q31,5,Business and �» Professions CodeJ: City., � Tel.No. - ❑ �,os owner of Ihe property,will do fhe work and�he � srrucroro�s not intandad or offered for wle (Section � - � , - � - 7Wa,Bus�ness and Profess�ons Code). � CONSTRUCTION LENDING AGENCY � � � � �- ' ' - - - � - � � � I hereby offirm ihot there is a mnshoction lending ogenty for . rhe perfamonce of rhe work for which rhis permil is issoed � � � � � � � � � (Sec 3097,Civ.C.). � . lender's Nome ' � lender's Addrees � I cerffy�hol I hove read�his applicotion ond sioie Ihot the � � - ► . . above informotion is carect.I aq�ee ro comply with oll CouMy � . ordinances ond S�ole laws regulaiing Plum6ing,and hereby . .. . . - . . .. amhorize represento�ives o(this Coumy to entx upon the � . � above-mentioned propeny for inspedion purposas. 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