HomeMy WebLinkAbout1222A WORKERS'COMPENSATIONDECLARATION ��4snw qPPLICATION FOR PLUMBiNG PERMIT �
, 1 hereby affirm that I have a'certificale of consent to self �E u�Iz-�o� � �
ins�re,or a certiCcate o(Workers'ComDensation Insurance,or . � ,
a certified copy thereof(Sec.3800,Lab.C.) � .COUNTY OF lOS ANGEIES BUILDING AND SAFETY � � �
Poticy T.i�O�CJ-_�Company3A�l!�rr��+ . - .
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �
AODRESS � �, .
�Certified copy is filed with e county uild'ng ins tion NUMBER FIXTURE OR ITEM � FEE �
d nrt e LOCALITY �A
WATER CLOSET
�cte �� " Appliten NEAREST
BATH TUB CROSS ST. � �
CERTIFICATE OP F.JCEMPTION FROM WOR C RS'
COMPENSATIONINSURANCE SHOWER OWNER �
LAVATORY M'�'�L
('fhis seclion need not be completed if the work invoived A�ORESS �
by the permlt is for one hundred dollars (5100)or less.) SINK ci7v TEL.NO. a
O _
- 1 certity that in ihe performance ot the work for which this DISHWASHER / D� U-
permit is issued,1 shall nof employ any person in any manner CONTRACTOR �,,,� • •
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so as to Necome subject to the\1'orkers'Compensation Laws. CLOTHES WASHER AOOHESS � _ O
Dete Applicant SWIMMING POOL RECEPTOR CITY TEL.N W
NOT[CS TD APPLICANT:If,after making this Certlficate of � �—�
Exemption, you should become subject to the Wnrkers' LAWN SPRINKLER SYSTEM �'
Campensation rovisions ot the Labor Code,you must forth- STATE [� LIC. N
0 LICENSE NO. '"7 �I CLASS ��� Z
with comply with such provislons or ihis�permit shall be� WATER HEATER —
deemed revnked. GAS SVSTEM OUTLETS DISTRI�O. PROiE55ED BYQ
LTCENSED CONTRACTORS DECLARATION OUTLE7S OVER !(i
I hereby affirm Ihat I am licensed under provisions of Chapter 5 PE R SYSTEM '
9 (commencing with Section 7000)of Division 3 of the Ausi• FINAL VALIDATION �
ness and Professione Code,and my Iicense is in full force and DATE
effect. . . �
INAL
License Number�l�f�,�� Lic.Class ��� BY
Contractor�(p�(i¢_ Date ����'���
� "� Plan check fee
1 am exempt from the licensing requirements as 1 am a
licensed atchitect or a registered professionai engi�eer pLUMBING PERMI7155UING FEE S � �
acting in my protessional capacity (Section 7051, Bus-
iness and Professiona Code). T07AL FEE
Lie,or Reg.N0. Date Plan<hack applicant �
�1GZ^cA
HOME OWNER-BUILDER DECLARATION Name - i� � �y � ' �
I hereby aCfvm thst I am exempt irom Ihe Contractor's Addrese � ���+ •1 C�!r
Ltcense Law for the following reaxon(Section 7031.5.Busi- eky � Tel.No. - � � � -
ness and Protasions Code): e I L r O-
� I,as owner of the property,am exclusively contrsetin� � - �'• �
w�ith licensed contrectors to construct the project (1 C�.� (:=jl��
(Section 7044,Rusiness and Professbns Code). . . � � �
CONSTRUCTION LEND]NG AGENCY � � .
i hereby affirm that ihere u �construction IenJing agency �
fur ihe performance of the work for w•hich Ihis permit is ' , , ._ .
issued(Sec.3097,Civ.C.). �
LendePs Name
LendePs Address
I certify that I have read this appiication and stale that the ,
above intormation is correcL I agree to comply with all County SEE REVERSB�OR EXPLANA70RY LANGUAGE
ordinances and State I9'AR regulating Plumbing, and hereby
autbo ize representatives oP this County to enter upon the �
above entioned prop r y or ins e lon purposes. �
� ��
nature of Permitree Date�
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