HomeMy WebLinkAbout0895A .WORKERS'COMPENSAiIONDECLARATION ' ��wsa♦ /7
I hereby afFrm tne� � he�e a'certi�cate of consen[to=e�f �a.,,,=-.o, APPLICAT.ION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or � .
'e certtfied copy thereof(Sec.3800,Leb.C.) • L�
COUNTY OF lOS ANGELES BUILDING ANO SAfETY
PolicyNo. �� Company � - � �
i -
��Certifed copy is hereby furnished. - FOR APPLICANT TO FILL IN fVRINT OR TYPE) BUILDING �'
ADDRE55� i. �"7� !JN 'L
� Certified copy iq fled with the county building inspection NUMBER FIXTURE OR I7EM • FEE
LOCAUTV
department. - WATER CLOSET �� � .
Uate ADDlicant NEAREST
` � BATH TUB . CROSS ST..�., wA-.��t.gi;— [�J
CERTIFICATE OF EXEMPTION FROM WORKERS' �
i � COMPENSATIONINSURANCE SHOWER � OWNER ��
LAVATORY MA�� L
(This eection need nat be completed if the wock invalved A�DRE55 hJ�►} }
by the permit is for one hundred dotlus (S1D0)or less.) SINK °'
. CITY, � � � TEL.NO. . y �
_f ttrtify Ihat in the performance�of the u�ork for which this DISHWASHER V
permit is iuued,I shall not emplo ny person ii ny manner CONTRACTOR � ��,ti �
�so as to become subject lo the r e,'Comp titi Laws. CLOTHES WASHER - AOORE33 � I
Date��ApPlicen W
SWIMMING POOL RECEPTOR �
NOTICE TO APPLICANT:It,a er making this Certificate ot C1TV TEL.NO.
Ezemption, you shouid become subject to the Workers' LAWNSPRINKLERSY6TEM STATE LIC. z
� Compensation prm•isions of the Labor Code.you must forth• LICENSE NO. CLASS �
,� with comply with such provisions or thi6 permil shall be WATER HEATER �
deemed revoked. GAS SYSTEM OUTLETS O� DISTRICT NO. PRpy�ESSEO BY
LICENSED CONTRACTOR5 DECLARATION OUTLETS OVER ` O �Q.t.tJt/
I hereby affirm thet[am Ilcenaed under prnvisions of Chepter 5 PE R SvSTEM
9(commencing with Section 7000)ot Divi�ion 3 of the Busi- 0� FINAL VALIDATION
ness and Profe55ions Code,and my license is in futl force and DATE �r �
effect. . � �
FINAL��Z (
License Number Lic.Ciass � BY
Contrector Dete � - � ��
� I am exempt from the licensing roquiremrnts as 1 am a Plan cheek fee �
licensed architect or a regislered professionsl engineet pLUM81NG PERMIT ISSUING FEE S �j
acting in my Orofessional capacity (Section 7051,Bus- . � .
inesx and Professiona Code). . TOTAL FEE � ,j(�
Lic.or Reg.No. Dete Plan cAeck applicant �
FfOME OWNF.R-BUILDER DECLARATION Nama
t hereby affum that 1 am exem0� frnm the Contractor's °'dd'�" �0 8 9,5 A �
License Law for thc following reason(Section.7071.5,6usi- ��ty 7eI.No. � �
�s and Rotessions Code): . N• • • • •5 �
1,as owner o(the proDerty,am ezclusively contrac[ing i
with Iicenud contractors to construct Ihe project �,• • � �5�
(Sec�ion 7044,Business and Professions Code). � � ,
• •�e.� �1J�c=.�
CONSTRUCT[ON LENDING AGCNCY . . - .
I hereby affirm �hat there is a conatruction lending agency �G�J—8�.�
for the periwmance of the work for which thls permit is . - --
issued(Sec.3097,Civ CJ. � - !
Lender's Name � '
Lender's Address � ��
I certify Ihat I have read Ihis application and state ihat ihe -
above information is correct.I agree to comply with all Cnunty . SEF.REV ERSE FOR EXPGANATORY LANCUAGE �
ordinances and State laws regulaling Ylumbing,and hereby
authodze ropresent v s of this Counly to enter upon the
abo - entloned p pe ty tor inspection purposes. . - . �
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ignature oC Yermiftee Date �
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