HomeMy WebLinkAbout1766A (10) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT � �
I here6y afii�m tha�I have a certificate of consem to self 76q��q .
insure,or a certificale of Workers CompenSolion InsVronte, CE BV(REV.l0/81) . . .
or o ce��d'co��e��5ec.�3eQo,l�C,��� COUNTY OF LOS ANGELES � BUILDING AND SAPETY
d`Y" �f� ���z ,
Cerrified copy is hereby f�rnished.
� FOR APPLIC.4NT TO FILL IN(PRINT OR TYPE) bUIL01NG I��6G ry_
Certified copy is filed with tha county building inspeo ADDRESS G "'�
�on dBpartmenl. � NUMBER FIXTVRE OR ITEM � -FEE
9 �J LOCALITV I�
Dofa�Appli4ol✓� �� � W/+TERCLOSET_ . NEAREST ( �_- �`
CERTIFICATE OF EXEMPTIQN FROM WORKER ' - 6.4iH NB CRO55 ST.��'V`�J�� r rn��-
COMPENSATION INSURANCE - � � OWnIER
(This��cflon nr�d no1 b�compl�Nd if fh�work inrolred by � SHOwER (.�
� 1h�p�rmlt b for on�hundnd dollan(SI00)or I�ss.) LAVATORY oDRE55 �� l�� ��� �
I certify thot in the�performonce of the work for which ihis '. _ �
� permit is issued,�sholl not employ ony person(n any manner SINK CITY !`u TEt.NO. _
so as to bacome subjetl to the Workers'Compensolion Laws. � -
. � OISHWASHER �� GOMRAQOR�����- �y1p l"�- �
Da�e OrP�icont CIOTHES WASHER ADDRE55 U I� � ,_(J .
NOTICE TO APPIICANT: If, after making this Cerlifimte of .
Exemp�ion, you sho�id become subject to the Worke�s' SWIMMINGPOOLRECEPTOR
Compensalion provisions of 1he Lobor Code,you musf Iorth- �AWN SPRINKLER SYSTEM CITV . h ` TEI. �'��' �
-�with comply wiih wch provisions or this permit shall be STniE � � �iC. /` �
daemed revokad. � . WATER HEATER IICENSE NO. GlASSI_/�
LIGENSED GONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I he�eby affirm fhol I am licensed�ndar provisions of Chapter 9 GAS$YSiEM - OURETS �
� � (commencing with$eclien 7000)of Divition 3 of�he Business OUTlET50VER
a�d Profeu�ons Code,and my license is in full face and effect. 5 a�k SvSieM FDIATEL Z �� VALI ION a
�3i��3 c� -� '�
License Numbe lic.Class p
���/_ �,/L j—�.5� FINAL U.
Con�roUo C���Yf�G'� ot BY �
❑ I am exempt under Sec . • �
U
8.87.C.fo�lhis reason - W
Plan check fee ► $1 7 G 6 Fl u°'i
Date' ' PLUMBING PERMIT ISSUING FEE E #� � � � �5 Z
SignaWre ' �
TOTAL FEE I • • � �5 O
. . . .. . _ . . �� . Plon check opplican� � _
SINGIE FAAdIIY • • • � �i J n c�
HOME OWNER-BUIIDER DECLARATION Name �
I hereby eNirm�ho�I om ezemp�from�he CoMrat�or's License � � ���0 a-II 7 �
Caw ior ine foiiowing reason($edion iu31.i,ousiness and '�'���Ps3 - . , �,
Proiessions Code): City Tel.No.
❑ I,as owne�of ihe properly,will do the work and Ihe
str�c�ure is not iNended or offered for sale(Section ► '
7044,Basiness and Professions Code). -� �
CONSTRUCTION LENDING AGENCY ... _ . .
I hereby nfiirm Ihot lhere is a tonslruclion lending ogen[y far
�he performonce of ihe work lor which this permit is issued � . _ .
(Sec.3097,Civ.C.�.
Lendeis Nome
Lender's Address � � � � �
I certify Ihat I have read Ihis opplicotion ond sta�e thot Ihe � � �
obove information is correcr.I agree to compiy wiih all Counry � � �
ordinontes and State lows reguloling Plum6ing,and heie6y
outhorize repreientolives of this County�o enter upon�he � � - � �
above-men�ioned properiy for inspection purpo✓es. C SEE REVERSE FOR EXPIANATORY IANGUAGE
v�--�- I �✓�
ignature of Perminee Dare ' " �
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