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HomeMy WebLinkAbout1770A (10) WORKERS'COMPENSATIONOECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm thot I hove o cerlificale of mnsent to self 20�0026�PW 6/87 . � � insure,or a c¢rtificote of Workeri Compensafion Insuronce, 76A667A . or a tertified copy thereof�Sec.3800,Lob.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS . � �POolityNo� .. .� Company 1 "., , ....i . Cerlilied copy is hereby fumished. D � FOR APttIfANT TO FlLL IN(PRINT OR NPE) BUILDING . � Cerlified copy is filed wilh the couny huilding inspec- A�DRESS —. %�/I i� / l��' " �ion deporlmenf. NUMBER FiXTURE OR ITEM C� FEE f ' ��� LOCALITY � l�„�J!.}1 :n( Do�e � ��} 1Applicont -�' WATERCLOSET NEAREST _. �i� CEIIfIF�CATE OF EXEMPTION FROM WORKERS' BA7H tUe CROSS ST. 7`:� :1 : 1< I`I V�� COMPENSATIONINSURANCE SHOWER OwnlEz �'� . /' , �� , � � ,�� �7hic��cNon n��d nof M tomplrlad I!th�work involv�d by ;� 1 �� the ermit��for on�hundr�d dollar� 5100 or I�s�. r'�0'�� ' � '� V I J ) LAVATORY A�DRE55'' � ! � .�^ f� =I,. I' I cerfify that In�he performonce of the work for whith Ihis . . .' � � permit is fssued,1 sholl not emptoy ony person in ony monner SINK � CITY j� �._ {.�� TEL.NO. i..,_. _ so as to become subject to rhe Worken'Compensation Laws. ois�+waSHER I ° CONTRACTOR� .. .� �_ , f Y pote epplimnt CLOTHES WASHER ADDRE55��-� I�� � � ! r- . NOTICE TO APpIICANT; If, oflnr moking ihis Carlificale of � • � � Exempt�on, you shou�d become s�bjact io the Workers' $WIhW11NGPOOLRECEPTOR Compensa�ion provisions of the lobor Code,you must forih- CiTv p� { TEI.NO.�,, � �r.:�- wifh [omply with such provisians or this permil shall be LAWN57RINKLERSYSTEM S7ATE . ` IIC. deemed ravoked. WATER HEATfR LIGENSE NO. �: �� (.�7 CV.SS �' � ��-� iM- �� IICENSED CONTRACTORS DECLARATION DISTRICi NO. PitOCESSED BY I hereby oHirm Ihaf I am licensed under provisions of Chopter 9 � GAS SY57FM OUTLETS � , \\ ����,' _ a (commencing with Saclion 7000)of Division 3 of the B�sinesz ouitETSOVER - � ' and Professions Code,and my license is in full force ond effect. 5�R SvSTEh� FINAL VALIDATION . v '�,;;' i 1�/ : f i-. "Jil' DATE License Number�' �� �- lic.Class� - � � � FINAI � Confratlor ..r- �^�r Dale '�_'• 7.� BY � ❑ � �om exempt under Sea ¢, ' B.BP.C.io�fhis reason - � Plan check fee , a, Date: PIUMBING PERMIT ISSUING FEE E �'-'(`j � W Signoture TOTALFEE � � Plon chetk applicant SINGLE FAMILY � HOME OWNER-BUILDER DECIARATiON Name � � - I hereby affirm thot I am ezemp�from the Contractor's license Address ��^ law for 1he following reason(Section 7031.5, B�siness ond r�h PrvFessicr,s Ccdc): City Tel.No. .�1,/;;f�Q�'. ❑ I,os owner af the property,will do the work and Ihe � �!,.��!,'!i.�...5, struclure is not in�ended or offered for sole(Section .., � 7044,Business and Professions Code). ,��!;;��,��G,J� CONSTRUCTION LENDING AGENCY - . '�,� � � I hereby nfiirm thol rhe�e is a mnstrudion lending ogency for , , '''I'"t'����' Ihe per{ormonce of the work(or which fhis permil is issued ,Q.O,��,�f1 S (Sec.3097.Civ.C.). - Lender i Nome . Lenderi Address (' ,�\?1�`�--� � I certify thal I hove reod this applicotion and state thot the � � � - obove informafion is corrett.I agree to comply wilh all Coun�y ordinances pnd Sta�e laws regulafing Plumbing,and hereby . , authorize,1epresenlo7ivts of this County fo enfer upon the - above-mentioned pr erly for inspeclion purposes. - SEE REVERSE fOR EXPLANATORY LANGUAGE ��` ��,�=~' , ;, ;;� �IynatOre�of Per'�tteer— ,Dafe . ' i � i � , � . i • , ; � , � . . ; , , � ' � .. . �4• 1 � � ! I 1 i . I � 1�_ �I � .. � i � . � � ' � . ; �.... , . ' • � , . . � .. I 1 � � , ._ � ; i � , .. i ' . � : � i i � . � - � i-- , -•- -- -� ' . � i -. i � j = , i i � ! �- . .. I ' ' j ! ' ' - �� ` I ' : � : � ! � : ; -.. . ! � E f ! � � � ! 1 � ' �, i � i , ; . i. -• , ._ . . ; i ' . . ��� . . .. . 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