HomeMy WebLinkAbout0801A .WORKERS'COMPENSATIONDECLARATION ��asstw �
1 hereby affirm Ihat [ heve a'certificate of consent to se�f �e.,,,=_.o� APPLICATION FOR�� PLUMBING PE�RMIT
insure,or e certificate o(Worken'Compensation Insurance,or �i � �
a certified copy thereof(Sec. �(La6.CJ � -��
o''c�.�f�('�Q�D� COUNTY OF LOS ANGELES �'` 'BUtt�NG AND SAFETI�•
' i —�3SJ�/
� Certified copy is hereby furn�shed. FOR APP�ICANT TO FILL IN(PRINT OR TYPE) BUIIDING �
ADDRESS (J O
CerHCed copy is fiied with the rnunty building inspection NUAriBEF FIXTURE OR ITEM • FEE ,.
�leputmen/ IOCALITY �J
�� ����1P���� WATER CLOSET �� O?�
Date Appliten� NEAREST
� BATH TUB QU CROSS ST.
CERTIPICATE OF EXEMPTION FROM WORKERS'
. . . COMPENSATIONiNSllRANCE SHOWER �/ OWNER � y��/
LAVATORV MAIL
(This aecNon need not be completed if the work involved � qooAe35 .e� �<✓
by the permit is Prn one hundred dollare (5�00)m IessJ SINK �� �-
� GCR� CITV �� TEL.NO.�jq_���, p _
- t certity lhat in the performanCe of the work for whlch this / DISHWASHER � d� f� U
permit is issuad,I shall not employ any pereon in any manner CONTRACTOR �e�� �„�
-. -1 �
i so as to become subject to the Worken'Compensation Laws. / CLOTHES WASHER UW ADDRESS�3 .��j7J `�.�� ��¢ O �
� � Date Appiicent ' SWIMMING POOL RECEPTOR V
`� NOTICE TO APPLiCANT:ff,after making[his Certificate oC CITY � TEL.NO.�J--f!'{C'p/ �
F.xemOtlon, you should become subject to the Workers' LAWNSPRiNKLERSVSTEM STATE /y r7 IIC. /� y,� N
CompensaHon provisions of the Lahor Code,you musYforth• � yyqTER HEATER �+�J LICENSE NO. .!i �✓!r.� CLASS L% ' "" z
with comply with such provisions or this permit shall be DISTRIC�O. PROCESSED BV
deemed revoked. l GAS SVSTEM ,�UTLETS �/
L[CENSED CONTRACTORS DECLARAT[ON OUT�ETS OVER
I hereby�affirm that I am Iicensed under prmisions of Chapter l 5 PE R SYSTEM � !/v
9 (commencing with Seclion 7000)of Division 3 of the Bus4 . FINA� � / ALIDATION
ness and Professions Code,and my license is in full force and DATE � Z7r� ,
ePtect. ,�
License Number J6/�Lic.Class �� � BY AL . • .
, p 7
Contractor Date T '��O / - - �
� I am exempt from th licensing requirements as t am a Plan check fee . ;
liCensed architect or a registered professional engineer pLUM81NG PERMIT ISSUING FEE S ,r7J
acting in my professional capacity(Section 7051,Bus-
iness and Pro[essions Code). TOTAL FEE ,�'�
Lic.or Reg,No. Date Plan ahxk applieant -
HOME OWNER•BUILUER DECLARATION Name =•G�Q 1 �. _ _
I hereAy affirm that I am exempt from the Coniractor'a Address � � � _ _ ��
License Law for Ihe followin¢reason(Section.703I.5, Busi• CItV - Tel.No. � T �
ness anJ Profasions Code): . � '� o .7�5 Q
� I,as owner of lhe proDerty,am exClusively contrecting �
with licensed contractors fo construct the Oroject ,��e�a']j�Q�
(Sec[ion 7044,Business and Professions Code). .
CONSTRUCTION LENDING ACENCY � ��C'n�r,,—2�
I hereby af�rm that there is a consfruction lending agency
tor the pertormance of the work for which this permlt is �
issued(Sec.3097,Civ.CJ. -
Lendet's Name
Lender's Address
1 tertity ihat I have read this applicetion and state�hat the
above information is correct.1 agree ro comply with all County SEE REVER5E 1'OR EXPLANATORY LANGUAGE -
ordinances and State laws regulating Vlumbing, and hereby
authorize repreuntatives of this County to enter upon the
a�bnoveI�mentioned proyp�e '�for inspection purposes. - �
,U nv��"0�2L/��cr:cw 5t'�`�'/
�nature of Permittee Date
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