HomeMy WebLinkAbout1224A WORKERS'COMPENSATfONpECLARATION �aw�ua APPLICATION FOR PLUMBING PERMIT . � �
�ereby affirm that I heve a certificate o[consent to self ee�n(z-eo�
�ure,or a certiftcate of Workers'Compensation Insurance,or ' -
:ertifiea copy thereof(Sec.3soo,Lab.C.) COUNTY OF LOS ANGEIES BUILDtNG AND SAFETY
�Ilcy N���3Company U��'r���`� . .. �
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PR�NT OH TYPE) gUILDING. � ��
ADDRESS
� Certified copy is filed with t e county uilding ection NUMBER FIXTVRE OR ITEM •. FEE . .
�e�� I IOCALITV
Date Applicant WA7ER CLOSET
NEAREST
BATH TUB CFOSS ST. � � �
�CHRTIGICATE Of•EXEMPTION FROM W ERS' �
COMPENSATIONINSURANCE SHOWER OWNER �
LAVATORV MAIL .. . . -
(This section need not be completed if the work invo�ved ADORESS }
by the permit is tor one hundnd dollus (5100)or less.) SINK CITV - TEL.NO. � _
— 1 certity that in Ihe performance of fhe work for which thts DISHWASHER • V
perrnit Is issued,I shall not employ any person in any manner CONTRACTOR , � F �
so as to become subject to the Workets'Compensation Laws. CLOTHES WASHER ADDRESS (j, �� - ��,F � �
Dete Applicanf SWIMMING POOL RECEPTOR V
NOTICE TO APPLIL'ANT:If,after making this Certificate nf CITY �- �'f TEL.NO. �l Wa �
Exemptlon, you should bec�me subject to tl�e N'orkers' LAWNSPRINKLERSYSTEM STATE LIC. z
Cnmpensation provisions of the Labor Code,you must forth- yypTER HEATER LICENSE NO. CLASS �—� _
with comply with such provisions or this permit shali be
deemed revoked. � �ISTRICT NO. PROCESSED BV -
GASSYSTEM OUTLETS � \�
LICGNSEDCONTRACTORSDECLARATION OUTLETSOVER � �
I hereby affirm that[am licensed under provisions af Chaptcr 5 PER SYS7EM
9 (commencing with Section 1000)of Divislon 3 of the Busi- �� ,n FINAL VALIDATION
ness and Rnfessions Code,end my license is in full torce and /1 DATE ,
effect.
License Number�� Lic.Clas.c �_�� BY �
Contractor�lLl.f�_ Date �'—��� . �
� � � v Plan check fee
I am exempt from the Iicensing requirements as I am a
� licensed architect or a registered proPessional engineer pLUM9INGPERMITISSUINGFEE$ �
acting in my pro(essional capacity (Section 1051,Bur ,
iness and Professions Code). � TOTAI FEE p� �
Lic.or Neg.No. Da[e Plan check applicant r, ��(�A
� '�e . .'e •F -
HOME OWNER-BUILDER DF;CLARATION Name " .
1 here6y afCrm that 1 am exempt from the Controctor's /+ddress' � .f'� �•1 ��r r
License Law for the foliowing reason (Section 703I.5,Husi• Ciry TN.No. � - � � � �" '� � ���'� '
ness and Professions Code):
� 1,as oumer of the OroDerty,am exclusively contracting - � O 9'� r—F� �
with licensed controctors to construct the project �
(Section 7044,Business and Professions Code). - � ' � �
CONSTRUCTION LENDING AGENCY - - � � '�
I hereby affirm that there is o constructlon lending agency�
tor the perlormance of the work for which this permit is � -
issued(Sec.1097.Civ.C.).
LeodePs Name .
Lender's Address � � �
1 certify that I hare read this applicsdon and state that the � ,
above information is correct.1 agree to comP�Y w'��h all County SEE RBVPRSE ROR EXPLAN�TORY LANGUAGE �
ordinances and State laws regulating Plumbing, and hereby
auth rize representatives of this Covnty to eMer upon the , , , ..
a6o �mentianed pe Prr y fnr' ection purposes. � ,
---�r -�
SgnatureofPermittee Date
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