HomeMy WebLinkAbout1223A (6) WORKF,RS'COMPENSATIONDECLARATIDN vee�aa � �
I herehy ajfirm fha� � he�e a'certiCcate oftonsent to u�f ceenlz-eo� APPLICATION FOR� PLUMBING PERMIT
Insure,or a rortificate ot Workers'Compensntlon Insurance,or . � � . ' �
a certiCed copy thereof(Sec.3900,Lab.�.) .
1��Boi t0 � /�/J�C�� COUNTY OF LOS ANGELES BUILDING AND SAFETV
Po1icY N .W �CComPanY �
� CertiCed Copy is hereby furnished. �FOR APPL�CANT TO FILL W(PqINT Ofi TYPE) BUILDING ��
AD�RESS
�CertiFed copy is fiied withrthe county bui�ding In� ction NUMBEF FIKfURE OR ITEM � FEE
ar e LOCALITY 1
Date � ' � Appliwn WATEN CLOSET NEAREST
BATH TUB CROSS ST. �
CERTIFICATE OI�EXEMPT[ON I�ROM WOR iR5'
COMPENSATIONINSURANCE SHOWER OWNER " �
LAVATORY MAIL }
(This section need not be completed iP the work involved � qooaEsS a
by the permit is fa one hundred doilars (S100)or IessJ SINK c�Tv TEL.NO. �
I certity that in[he periormance of the work for which this oiSHWASHER � �
permit is issued,I shall not employ any person in any manner CONTRACTOR �� _ �
so as to become subject to the Workets'Compensal�on Laws. CLOTHES WASHER pppRESS �/ � (~j �
Dale Applicant �� N� — w
SWIMMING POOL RECEPTOR p.
NOTICL•TO APPLICANT:If,after making this Certificate of CITV TEL.N _ �
Ezemplion, you shouid become subject to ihe Wnrkers' LAWN SPRINKLER SVSTEM STATE LIC. z
Cnmpensatlon provisions of the Labor Code,you must(orth- yyqTER HEATER IICENSE NO L C�ASS �'"���
�vith comply with such provisions or this permit shail be OISTRICT NO. PROCESSED BY
deemed revoked. GAS SYSTEM OUTLETS �7 �
LICENSED CONTRACTORS DECLARATION OUTLE7S OVER � v l C
I hereby affirm that I am licensed under provisions of Chapter s PER SVS7EM
9 (enmmencing with Section 7000)of Divisinn 3 of the Busi• FINAL VALIDATION �
ness and Professions Code,and my license is in full force and DATE . - �
effect
License Number��I7�L Lic.Class �`2� J BY AL
�—��`�/ .`� 22�A
Coniractor�{vn� Date � � + �� .
n.• r >
� 1 am exempt Crom lhe licensing requirements ss 1 am a Plan eheek fee � .
Iicensed architect or a re¢istered profeuional engineer pLUMBiNG PERMIT ISSUING FEE$ �t' ''1 2 V�
� acting in my profeasional capacity (Section 7051, Bus• � s
inees and Professions Code). . � 5� � � � �^�1 T
TOTAL FEE
Lic.or Reg.No. D9te Plan cbeck applicant !i� 1�l'—� � -
-HOME OWNER•BUILDER D£CLARATiON Name � . . '
I hereby atfrm that 1 am exempt irom the ContractoPs Address
l,lcense Law for the following rcason(Section.70�1.5,Busi- City Tel.Na. - - - �-
ness and Prnfetsions Code): �
� 1,as owner of the property,am exciusively contracting � - � � ��
with Iicensed contracton to construct the project
(Section 7044,Business and Professions Code). � - � ��� �
CONSTRUCTION LENDING AGbNCY . - � � � -
1 hereby a(firm thet there is a conseruetion lending agency
for the performance of the work for which this permit is . ._. . .
issued(Sec.3097,Civ.C.).
Lender's Neme
LendePs Address � -
I certify that I have read this application snd state that the
a6ove information is correct.I agree to comply with all County . SEE REVF.RSE FOR EXPLANATORY LANGUAGE - � � ��
ordinances and State laws regulating Plumbing, and herz6y -
autho ize represenfatives ot tbis County to enter upon the �
abov entioned pr for i ction purposes. � � � �
_�J .
Signature of Yermittee Date
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