HomeMy WebLinkAbout1782A WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT � �
1 heieby offirm thot I have a certificate of consent to self 7eA667A
insore,or a cerlifito�e oi Workers'Compensation Insvronce, . CE BV(REV.10/81) . . ' _
or o cernfied copy th of S Lob. ) �
��G�����; / ��� _ _ � COUNTY OF l05 ANGELES BUILDING AND SAFETY
POolity N Compony `f-�Y�
Ca�Yfied copy is hereby furnished. �
� . ' FOR APPLIfJ1NT TO FILL IN(PRINT OR TYPE) �IIDING ! /����-y_
Cerlitied copy is Filed with Ihe muNy building inspec- A�DRE55 L�-E •�r�
tio deporlmenf. � /7 NUMBFR FIXTUREORITEM @ FEE ���ITY
Date ���ppli4aM , _F-GL'C�'.. WATERClOSET NEAREST 9 � � `�U /^,� � � .
CERTIFICATE OF EXEMPTIQN FROM WORKERS' BATH Tue CRO55 ST.LC%ln'L� �r"�'!�,
COMFENSATION INSURANCE � OWNER - �� -
(This�ection nead no1 6�complef�d if Ihe work Invol d by SHOWER
Ihe parmlf h(or ona hundnd dollan(SI00)or bss.) LAVaTORY qooRE55 � / ��'� - -
I certify thot in the periormance oF�he work for which this i�
permit is issued,I shall nat employ any person in ony manner � SWK � - CiTv r '"11� TEL ta0. C�C.�O
w as fo become subject fo the Workeri Compensotion Laws. DISHWASHER -�f� ��
CONTRACT '� ���� ��
pafe� 6PPlimnt � CIOTHE5WA5HER ADDRFSS `y,� r� „p
NOTICE TO APPLICANT: If, offer moking lhis Cer�ificate of
SWIMMING POOL RFCEPTOR
Faemption, you should become subject to �he Workers' CITV ./�/ E1.NO. �'
Compensation provisions of 1he La6or Code,you musf Iorth• �AWNSPRINKlER5Y5TFM ^ r�-' � ��
with comply with s�ch proviaions or this permil shall be STATE Z.�� LIC. /� �
deemed revoked.� � � � .. - WATER HEATER � IiCEN$E NO. �ciV ClASS L/
. lICENSED CONTRACTORS DECLARATION , �iSTeiCT NO. aROCF55eD Bv
1 hereby offirm thot I om licensed under provisions of Chop+er 9 � GAS SYSTEM � OUTLETS - + � �
(commenting wi�h Setlion 7000)of Division 3 of�he Business OUilEi50vER .
ond P�ofeu�ons Code,ond my I�cense�s in f�ll face and effecr. 5 vea Svsrer� FINAL VALI TIQN
�j'� �j /� DATE a�
license Number �✓/V�� lic.Classv�
O,
���/ __ „_/j���G� FINAL U.:
Controdc � L.,Pi'l(�` o O . BY
��
❑ �
I om exempt under$ec. `1 .1�2� U
B.BP.C.for this reason ► W
- Plon check fee �. . . . .5 a
Date: p�UM81NG PERMIT ISSUING FEE E I � � ' �5 O Z
�Signature —..
TOTAL FEE
• • • � (,JOU
_. . . . _ .. . � Plan check applicant
SINGIE FAM�LY 0 1.0 8—8 7
HOME OWNER-BUILDER DECLARATION Name
I hereby aifirm iho�I om�exempl!rom�he CoNroUor's l7cense Address
:cw fct tFa` lcw�irg raascn(Sa.ticn 7Q3L5,�us�r�ass and
Professtons Code): Cily Tel.No. -
❑ I,as owner of the praperly,will do Ihe work and the - , � -
srructure is not iMended or of(ered for sole(Seclion �
7044,8us�ness and Profess�ons Code). - �� � - � � - � � �
:ONSTRUCTION LEN�ING AGENCY _ .. . . . . . . . _ .
I hereby nflirm thol Ihere ie a construction lending agency(or .
Ihe performonte of the work for which this permit is issued _ _ ___ _ , � _ . .
(Sec.3097,Civ.C.J. .
lender's Name . . , . . .. . . . . . . . . . .
Lender's Address � � � �� �
I certify rhat I have read this oppl�cor�on ond srare thof fhe �,
obave informo�ian is mrrecf.I agree lo mmply with all County - � "
ordinonces and Slole laws regulating Plumbing,and hcreby _
aulhorize represenlatives of Ihis CouNy�o enter upon the . � � �-� - � - � � � -
above-mentioned ropeny for in ection purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE
� 1-7�7
Signciore of Perm�vee Date . � � � - � � -
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