HomeMy WebLinkAbout1225A (6) WORKERS'COMPENSATIONDECLARATION �e�e��w qPPLICATION FOR� PLUMBING PERMIT {�
1 hereby af�rm that I have a'certificate of consent to self ce en Iz-eo1
insure,or a certificate ot Workers'Compensation Insurance,or � ��
a certified copy thereof(Sec.3900,Lab.I C.)�1 �� COUNTY OF LOS ANGELES BUI LDING ANO SAFETY
Policy NrL.62JGllfC��npany U,V��L X C_ � � .
� Certified copy is hereby turnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r .
�rrr---yyY ADDRESS� L�7 �L '�L
Certified copy is tiled with e county il ing in linn NUMBER FIXTURE OH ITEM • FEE
Date a v Appiitan WATER CLOSET LOCALITV �u
NEAREST
BATH TUB CROSS ST. 1
CERTIFICATE OF EXEMPTION FROM WO RS'
COMPENSATIONINSURANCC SHOWER OWNER .
(This section need not be completed it the work involved LAVATORY - A��RESS � a �
6y the permi[ is for one hundted dollars (SI00)or less.j SINK CtTY - TEL.NO. �U
— I certify that in the performance ot the work(or which this DISHWASHER / n', d O,
permit is issued,I shali not employ any person in any manner CONTRACTOR �__»/ +�
so as to become subject to the Workers'Compensatlon Laws. CLOTHES WASHER / V
ADDflE35
Date Applicant SW�MMING POOL RECEPTOR W
NOTICG TO APPLICANT:If,after makin this Certificate of CITY TEL.N �'
Ezemption, you should become subject tn ihe Workers' � LAWNSPRINKLERSVSTEM � STAT ��`` LI0. / Z
Compensatinn provisii�na of the Labm CoJe,you must Forth- WATER HEATER LICENSE NO.. � CLASS C�—
with comply wilh sach D�ovisions or this permit shafl be
deemed revoked. GAS SYSTEM OUTLETS DISTR�CT NO. ROCESSED BY
UCENSEO CONTRACTORS DGCLARATION OUTLETS OVER Z ��`�` � �
1 hereby affirm that I am licensed under provisions of Chapter 5 PE q 5YSTEM
9(commencing with Section 7000)of Division 3 of the Busi• � FINAL
ness and Protessions Code,and my iicense is in full force and �ATE VALIDATION
effect. r
License Number � ^�� Lic.Class C�� AL
/ B
Contractor�a,�.� Date����`�!
� I am exempt from ihe Iicensing requirements as I am a Plan check fee __�'�7 F q.
licensed arehitect or o registered profeseional engineer pLUMBING PERMIT ISSVING FEE S
actinB in my professional capacity(Section 7051, Bus• U +! . e r e�
iness and Ro(essions Cnde). 70TAL FEE '
� � .� • •�� C.rC �
Lic.or Reg,No. Date Plan check applicant
. , �12.50:
IIOME0�1'NER-BUILDERUECLARATION Name
i hereby afHrm that I am ezempt from the Contractors addrns
09.11t—F?t
License Law for the following reason(Senion.7031.5;Busi- . City Tel.No. � �
ness and Professions Code): .
� 1,as owner of the properry,am exclusively contracting -- - �
with licensed contractors to construct the project
(SecNon 7044,Business and Yrofessions Code). . . . . .
CONSTRUCTION LINDING AGIiNCY �
1 hereby atfirm that there is a construction lending agency '
for the performance oP ihe work Por which this permit is �
issued(Sec.3099,Civ.C.). - -
Lender's Name � -
Lender's Address
I certity that I have read this app�ication and state that the . - .
above information is correct.1 agree to comply with all County SEE RF.VERSC FOR EXPLANATORY LANGUAGE
ordinances ond State laas regulating Ylumbing, and hereby � -
author' e representatives of t¢is County to enter upon the
ahove� entioned p r (or ection purposes. - - �
�
Si ature of Permittee ate '
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