HomeMy WebLinkAbout1221A V.'ORKERS'COMPENSA7IONDECLARATION �°���9� APPLICATION FOR PLUMBING. PERMIT � -
� I hereby affirm that 1 have a•cerlificate of coment to scit ce n�(z•eo� �
� insurc,or a certiCcate of Workers'Compensation Insurance,or . _ � .
a certified copy thereof(Sec.3900,Lab.C.)
1��� .,� �1,�. /I COUNTY OF LOS ANGELES BUILDING AND SAFETY
YolicY No�c�-C=�r-�mpam,l4/t//' QF . . . � .
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPEI BUILDING � -
ADDRESS
� Certified copy is filed with e county building i p tion NUMBER FIX7URE OR ITEM � FEE
� m � WATER CLOSET LOCALITY h S .
Date Applicant NEAREST
� BATH TU8 CHOSS ST. �
CERTIFICATE OF EXEMPTION FROM WO RS'
� COMPENSATfONINSURANCE SHOWER - OWNER � � •
LAVATORY � MAIL � . . .
(This section nced nat be completed if the work invoWed ADDRESS
by the permit is for one hundred dollsrs (5100)or less.) SINK �- �
CITY TEL.NO. �
— 1 certify that in ihe perCormance of the work for which this oISHWASHER V
permit is issued.I shall not empiny any person in any manner CON7RACTOH �
sn as tn become subject to the R'orkers'Compensation Laws. CLOTHES WASHER AODRESS u ' � F O .
Date Applicant SWIMMING POOL RECEPTOF oV ��TY � � TEL.N0�3.�qb a
NOTICE TO APPL(CANT:If,aRer making[his Certificate of
Exemptinn, you should become su6ject t� the Workers' LAWNSPRINKLERSYSTEM STATE LIC. r «
Compensation provisions nf the Labm CoJe,you must forth• UCENSE NO. CLASS� C�� z
v.�ith comply�with such provisions or thix Oermit shall be WATERHEATER —
deemed revoked. DISTRICT NO. PROCESSED BY �
GAS SYSTEM OUTLETS ^ � ^
LTCENSED CONTRACTORS DECLARAT[ON OUTLETS OVER �- v �
I hereby atfirm that 1 am Iicensed undet pr�visions of Chepter 5 PE R SYSTEM
9(commencing wl[h Section 7000)ot Division 3 of the Rust- - FINAL VALIDATION
ness and Professions Code,and my Iicense is In full torce and DATE
effect.
�J F
License Numbe� Lic.Clasa �— � / v '
Contracto�(�(� Date � �
� I am exempt from the littnsing requiremenls as I am a Pian eheck fee ��
licensed erchitect or a registered profe6sionai engineer pLUMBING PERMIT ISSUING FEE S • (�
actfng in my profeuiona� capacity (Section 7051, Buz• r �� �2�� jz '
iness and Rofesxions Code). � TOTAL FEE � d . -
,'�;� • • •�
Lic.or Reg.No. Date Plan chack applicant - � '
Name , •� •y� �.r,�`, -�
HOME OWNHR•BUILDER DECLARATfON �
1 hereby affvm that I am exempt tmm �he Contractor's Addrees � • ° • � ��i+� �
License Law for the following reason(Section.7031.5,Busi- City Tel.No. � �� � �C G,� j(<f`,�
ness and Protessions Code): ,
� I,as owner of the property,am exclusiveiy contracting � -
.kdth licensed contractors to construct the project .
(Section 7044,Business and Profess'wns Code). . � � � � �
CONSTRUCTION LENDING AGGNCY �
I hereby affirm that there is a constructlon lending agency
for the pertormance of�he work tor which this permit is .
issued(Sec.3097,Civ.C.). ,
Lender's Name � � .
Lender's Address
1 certity that 1 have read this applicstion and state ihet the . �
above intormation is correct.I agree to comply with all County • SEE REVERSG POR EXPLANATORY LANGUAGE - - �
nrdin�nas and State laws regulating 1'Iumbing, and hereby
authorize representatives oi this County to enter upon the .
ab��en� r per or Inspection purposes. �� �
�
Signature nf Permi Date _ �
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