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HomeMy WebLinkAbout0800A (4) WORKERS'COMPENSATIONDECLARATION va�a�a � 1 hereby.af�rm that I have �certificate ef�o�s�,<<o9e�f �e.�,«-.o, APPLICATION FOR PLUMBING PERMIT insure,ot a certificate of Workers'Compencation Insurance,or . � , �` � a etlfi d cop thereof Sec.3 0 eb /!�_��-��-�3v�� �� � COUNTYOFLOSANGELES ._. -•-�-- -•�� BUILDI GANDSAFETY�; Policy No. ComDany � - / �3S � - � CertlfjeA copy is hereby furnished FOR AP�LICANT TO FILL IN(PRINT OR TVPE) BUILDING � � _� Cer/ified co h filed with Ih munt buiidin NUMBER FIXTURE OH ITfM • FEE '4�ORESS ��'j . PY Y �/H inspection deputme t �/J /J_^ LOCALITY Dat�Appllcant +</� Cr� N�ATER CLOSET NEAREST - BATH TUB CROSS ST. � CERTIFICA7E OF B%EMPTION FROM WORKERS' � � - COMPENSATIONINSURANCE � SHOWER � OWNER ��� ' LA.VATORY MA�L ��� ' (This section n«d not be completed if tbe wock invoWed � qooAeSs� u..e��� J by the pem�it is tor one hundred dollars(S10D)or less.) SINK �� a 1 - OtiP� GTV y� TEL.NO�-i9'f/lU 0 -� _� {certify that in the pertotmence of the work for which this �ISHWASHER Q�-!� permit is issued,I ahall nnt empioy any person in any manner CO TRACTOR �� [��� � so as to become subject to the Workera'Compensation Laws. CLOTHES WASHER N ADDRESS �Z - �� � Dete � Applicent SWIMMING VOOL RECEPTOR �� V � � NOTICE TO APPLICANT:]f,after making thls Certificate of CITY� TEL.N0.9���!'p� W � . ExemOtfon, you should become subject to the Worketa' LAWN SPRINKLER SYSTEM ) � � CompensaHon prnvistons of the Labor Code,you must forth- � yyqTER HEATER Q.-y L CENSE NO. ��O C ASS �'� Z � wi[h comD�Y w'ith such provibions or this permit shall be DISTHICT NO. PROCESSED BV deemed revoked. � GAS SYSTEM OUTLETS � . LICENSED CONTRAC70RS DECLARATION OUTLETS OVER ' 1 hereby affirm that I�am licensed under provisions of Chapter � 5 PEF SVSTEM 9(tommencing with Seclion 7000)of Division 3 of the Busi- - FINAL ALIDATION - ness and Professions Code,and my license is in full force and DATE �/J�� �� e/fect /� ' / License Number i�y��d Lic.Claas `� " eY AL ��jl � Contractor /7b Date����/ ' � !am exempt from th licensing requ'vementa as 1 am a Plan check fee . licenud architect or a registered professional engincer pLVMBING PERM�T ISSUING FEE S �fY] . � . acling in my professionsl capacity(Section?051,Bua- � . iness and Rnfessions Code), . TOTAL FEE ' � Lic.or Reg.No. Dafe Plan check appliunt . HOME OWNER-BOILDER OECLARATION Name - - 11 hereby affvm thaf i am exempt kom the Contmctor's Addra�s . iicense Law for thc following reasan(Section 7031.5,6usi- City Tel,No. � - �less and Profasinns Code): �(�,II Q O P� � I,as owner of the properfy,am esdusively contracting � � with licenaed contractors to construct ihe project H . . .s s 5 (Section 7044,Business and Protessions Code), CONSTRUCT[ON LENDING ACENCY ' � �7 7 y C hereby etfitm thet tbere is a consfinetion lending agency � C ;L - �or the pertormance of Ihe wotk for which this permit is , •"'•7 7�Q xc .� s " v °a � G� r p T'� N t'ti .p G C -� -c � � v '^ '� vc,� 5. �' �. .� � �� 9 "2 � � '� a T'.� Z 2 r � O aG � ��1 � C, p � C: � � < �.V� ' '., 'J 'f t � L lP \ �31 O-� \G �� � � � 2f ' �,, � 9 : �\ 0 . � � \ ��O e . ' f `("� ;t a q� � .'`.. , �;' ,', , '� �\. ` , � ��� . - .. . . , . � � �\_� - ' `a Z , �z . . � ,�'Nv' . � • N , . ..� ' _ '� . G�Z . . n ' . � . . . � - . • �i � . . , '.1 . G � � . �. �� N � �. 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