HomeMy WebLinkAbout1772A (10) � WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT {� �
I here6y affirm thal I have a certificale af consent to self 76A667A
insvre,or a certifica7e of Warkers'Compensalion Insurance, . CE B17(REV.10/Bl) . . .. LI
or a cerrfied�� py rher�eo�4c.,2BD0,tob. `����� COUNTY OF LOS ANGELES 6UILDING AND SAFETY
,:ltc�—
POolity No.l� ompanY .
Cerlified copy is hereby furnished. 8111LDING �J�p / �.,� � � ,,/J
FOR AFMICANT TO FRL IN(PRINT OR TYPE) ADDRE55 � C.�v� (.�7�� � C�'�
�iCerlified capy is filed with ihe caunry 6uildlnq inspec-
tion deporfinent. . - ` n NUMBER FIxTURE OR ITEM C<g FEE ����TY � � . 7
Da�e I � � APPliqony� '�L":" . WATERCtOSET NEAREST / �, �v �
� CERTIFICATE Of EXEMPTION FROM WORKERS' BaTHTUB CROSSST.C�('�'Y-7f�1 ! �-
COMPENSATION INSURANCE OWNER r' �
(Thit��efion n��d not b�compl�t�d I!1h�work involv�d by SHOWER
MAIL I C,C.� . A�1 ?�
Ih�p�rmit ir!or en�hundred dellar�(5100)or I�sa.) LnVaTORY ADDaE55 ( 'vl
� I cerfify that in the perfamance of the work for which th�s
permit is issued,I sholl no�employ ony person in any manner - SINK C�N• �G.� J� TEt.N���
so as to become su6jecl fo ihe Workers'Compencafion laws. . DISHWASHER
. CONTRAROR �LGJYI
Date Applitonl ' ' CLOTHES WASHER ADDRESS ` � �1
NOTICE TO APPIICANT: It, afrer moking this Cartifica�e of
Exemplion, yo� should become subject to the Workers' SWIMMINGGOOLRECEPTOR �
Compen5ofion provislans of fhe Lobor Code,you musl farlh• �AWNSDRINKLERSYSTEM CIN �'�/`� TEL.N � ��
wi�h comply with such provisions or this permit shall be STATE /1.� ��� UC.
deemed revoked. � � WAtER HEATER LICENSf NO"[ fLASS
IICENSED CONTRACTORS DECLARATION DiSTRiCt NO. ESSED Bv
I hereby affirm thol I am licensed undar provisians of Chaplar 9 GAS SYSTEM �� OUREiS � � .
- (commencing wilh Seclion 7000�of Division 3 of Ihe 8usines5 OUTLETSOVER ,
and Rofeuions Code,and my license is in full force and effeU. S PER SYSTEM FINAL VALIDA Q�1 �
!`� ��`�j �-7 DATE ,,,�I�/a+ d
License Num6er�v��""'' lit.Gas��� O
/ C,��_y�,.�,�� S�� FINAL C�.
ConlractoY��� Ualy�••E� �� "' BY
�
❑ I om exempt under Sec. � U
B.BP.C.for this reoson � �+1
Plan check fee . ► d
Dote: �
PLUM8ING PERMIT ISSUING FEE 5 � ^
Signature �� '7�].`2,q
TOTAL FEE
. .. _ . .. Plan check opplicant - - #• • • • •$
SINGLE FAMILY � � � � �Jr O
HOME OWNER-BUILDER DECLARATION Name � � .
I hereby af(irm�hat I am exempl Irom the Conlrac�or's License Address � • • • 1 �5 O'� �
. low for ihe following reason($etlion 7031.5,Business and � ��
Professions Code): City rei.No. 0 1,0 8—II 7
❑ I,os owner of the property,will do Ihe work and the
s�roc�ure is not intended or offered ior sale(SeUion ► -
7044,Business ond Pro(essions Code). � - � � '
CONSTRUCTION LENDING AGENCY . . . . _ . .
I here6y nfFirm thot ihere is a tons�r�tlion lending agency for
the performonce oi the work for which this permit is issued .. ., , , . ., . . . , .
(Sec.3097,Civ.C.).
Lender's Name
I
Lende�'s Address � �� � �
I certify tha�I have read ihfs applica�ion and state tha�the ,
obove inFormorion is cor�ect.I agree ro comply wirh all Co�nty ' � .
o�dinonces and Sta�e lows regoloting Plombing,and hereby �
ouihorize representa�ives o(this Coun�y to emer upon the - - � - �
obove-memioned property for inspe+�on purposes. � �
SEE REVERSE FOR E%PIANATORY LANGUAGE
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Sign ture o1 Perminee Date � � � - -
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