HomeMy WebLinkAbout0799A WORKERS'COMPENSATfONDECLARATION vewsaw
I hereby e«�m ,h8� � ha�e a'certi�cate �f cnnsent to se�f �E.,,,=-.o, APPLICATIO_N FOR PLUMBING PERMIT �
insure,or a certificale of Workers'Compensation[nsurance,or
a certified copy ihereot(Sec.3800,Lab.C.) �
�+ao,_3�„/p�pyri COUNTY OF lOS ANGELES • BUI LD G AND SAFETY
. �J �
Policy No. Company �a "'��i�-.,_7����
� Cert' c py is hereby(urnished. FOR APPLtCANT TO FILL IN(PRINT OR TVPE) BUILDING �/ �
ADDRESS O/li�
Certified copy is filed with the cnunty huilding i spectio NUMBEF FIXTURE OR ITEM • FEE _
�leparimen}. �/o����/��� WATER CLOSET / �� LOCALITV _/_f
Dat�L Applicant�L`-�-�"'•"� � NEAREST
� � L�• BATH TUB �/ CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
� COMYENSATION iNSURANCE � SHOWER pt� OWNER �_p�'
� � LAVATORV MAIL / v
(1'his eection need not be completed if Ihe work involved � O�U nooaEss � � _�u�...���-� c}i
by the permit is Por one hundred dollars (SI00) or IessJ SINK pr �`"� �� �
p� p. /i v CITY��� N TEL.N0��9_ �Jp (�
I certity that in the performence of the work far which this DISHWASHER 0'A �
� CONTPACTOR�L�� ���H�
permit is iasued,1 shall not empioy any person in any manner u O
so as to become subJect to the Workers'Compensation Lawa. ` CLOTHES WASHER � Q�d ADDFESS�33�Z/ ,T��/���- (~j
Date Applicant SWIMMING POOL RECEPTOR pW, �
NOTICE TO APPLICANT:If,aiter making this CertiFcate of dTV TEL.NO.��.�� �
Exemption, you shou]d become subject to the Workers' LAWN SPRINKLER SYSTEM � STATE p LIC. �,/ z
Compensalion provisions of the LaFor Code,you must forth- yyqTER HEATER QMl LICENSE NO.l�7�� CLASS ���"�
� wilh comply with such provisinns or this permif shall be
deemed revoked. GAS SVSTEM �OVTLETS � �ISTiiICj,NO. ROCESSED BY
r„
LICENSED CONTRACTORS DECLARATION OUTLETS OVER �S
I hereby af£vm thet 1 am Iicensed onder proviaions of Chepter � 5 PER SYS7EM - ��U �
9 (commencing with Sectlon 7000)of Division 3 of the Busi- FINAL � VALIDATION
nese and Professions Code,and my license is in full Corce and DATE /Q -?,7 �
effect.
/I� � FINAL �
License Number�/ �Lic.Class v � BY ��/"���
Contractory�-� Date�����J
/
� J Plan check fee
1 am exempt from Ihe licensing requirements as I am a
�icensed architect or a registered professional engineer pLUMBING PERMIT ISSUING FEE S � �
acting in my professionel capacity (Section 7051.Bus- .
iness and P*nfessions Code). TOTAL FEE �� ,
Lic,or ReR.No. Date Plan check applicant � .
I�OMEOWNF:R-BUILDERDECLARATION Nams •
1 here63' affum that I sm exempt from the Contractor's Addres� ��'�Q C�A •
License Law for the foliowing reeson(Section 7031.5,Ausi• City � Tel.No.
ness and Rofessions Code): �#'� �h,�� �5
� 1,as owner of the property,am ezclusively contrecting � � .�.!;�7�J�
with licensed contrac[ors to construct the project ,
(Section 1044,Business and Professions Code). - � • s'e?�J Q�i
CONSTRUCTION LENDING AGENCY e;�^;�
1 hereby affirm that there is a construction lending agency ���": �v �
tor the performance of the work for which this permit is . '
issued(Sec.3097.Civ.C.). �
Lender's Name � �
LendePs Address � .
I certify that 1 have read this application and state that the �
a6ove intormation is correct.I agree lo comply with a1l County SF.F.REVF.RSE FOR EXPLANATORY LANGUACE
ordinances and State laws regulating Plumbing, and harcby �
autborize representatives of[his Counry to enter upon the
above•mentioned proDerty tor inspection purposes. . �
������ �-�=•— !��_��
��Signature of Permittee Date .
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