HomeMy WebLinkAbout1128A (5) WORKERS'COM?ENSATIONDECIARATION APPLICATION FOR PLUMBING PERMIT �
I here6y,offvr�thm I have a certifiro�e of conseni to seli 76A667A
insbre,or¢t;`lifimte of Workers'Compe.nsotion Insurance, CE 817(REV.IOi81) � •
or o carlifie�iopy thereoi(Sec.3800,La6.C.� COUNTY OF LOS ANGELES � BUILDING AND SAfETY
O�3N�ao3v�-Cg°3�o�Y �r�riodWin�muru,�
Cerfified mpy is hereby iurnished.
fOR APPl1G1NT TO FlLl IN(PRINT OR TYPE) BUILDING
� Certified mpy is filed wi�h�he county building inspec- nDDRE55 Q
�iondepartment. � NUMBER - Fl%7UREORREM � FEE �aALITV
Date h'��1'�/ Applimnt �Y/TERCLOSET {Q•U� QO NEAREST
CERTIFICATE OF EXEMPTION OM WORKER$' eATH TUB OD CR055 ST.
COMPENSATION IN RANCE OWNER
(This�eetlon naad nof ba completed f1 tha work Inrolved by SHOWER
M,4�1
Ih�permif it for on�h�ndr�d dollors(5100)or I��s.) �AVATORV Q ADDRE55
�certify thot in ihe per{ormance of the work ior which this .
permil is issued,I sholl nof employ ony person in ony monner - SiNK � g Q p CITY TEL.NO�� �
so as�e become su6ject to Ihe Workers'Compensalion laws. DISHWASHER �
. I � CONTRACTOR �
Dale Appli[onl � CLOTHES WASHER (� qppRES$
NOTICE TO APPLICANT: If, o(ler moking Ihis Certificate of SWIMMINGPOOLRECEPTOR
Eaemption, yo� sho�ld become subjecf to the Workers'
Compensatian provisions o(the La6or Code,you m�st forth- LAWN SPRINKLER SYSTEM ��TY �TE� NO � ,��
with,comply with such provisions or Ihis permit sholl be S1ATE LiC.
deemad revoked. WATER HEATER L�CENSE NO. Ufl CLASS �.
LICENSED CONTRACTORS DECIARATION �U DISTRICT NO. OCESSED BY
I hereby oHirm Ihot I om licensed��nder provisions of Chapfe�9 ' GAS SVSTEM OUilETS � f O
(commencinq wnh Sedion 7000)of Division 3 oi ihe Buatness ounersovee d
and Profeu�ons Code,ond my I�cense is in lull(orte and effect. 5 aER Sv57EM FINAL �7 VAIiDATION
3'J,��D D G 3 f� DATE L }
license Number Lit.CIo55 , . Q �
��.�pp-� FINAL U
Comroctor Da�e_,1'�o'L� BY �.
❑ I am a mp�onder Sea � � '
U
8.8P. .for�his reason W
Plan check fae � 0„�.
Da�e: N
PLUMBING PERMIi ISSUING FEE E D �� � 2,H A Z
Signoture
TOTAI FEE
�. . ... .5
. - . Plan check oPPlicant �� • � Q Q 5 b
SINGLE FAMItY .
HOME OWNER-BWtDER DECIARATION Nome • • 1 4 E.5 0 c=i -
I hereby affirm�hot I am exempt from�he Controctor's License Address �
Law for the foilowing reoson(Seclicn 7031.5,Business and � U O,L O�O I
Profassfons Code): � Ciiy Tel.No. � �
❑ I,os owner of fhe prope�ty,w�ll do the work and the '
structure is not iMended or offered for sole(Section ,
7044,Business and Professtons Code). .
CONSTRUCTION LENDING AGENCY
I heraby nffirm that there is a conslruction lending ogency for .
the perfarmance ai Ihe work for which Ihis permit is issued
(Se[.3097.Civ.C.). . . . . .
lender's Name - - � �
Lender's Address � -- � �
I certify tho�I hove read�his application and state ihat ihe ►
obove informolion is correcl.I agree fo camply with all Counry .
ordinances and Slale lows regulating Plumbing,and hereby
ou�horize representotives of this Co�n�y to enter upon�he .
above-mentianed property For inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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