HomeMy WebLinkAbout0798A WORKERS'COMPENSATI6NDFCLARATION o��eo�
I heroby affirm �hat 1 have a certi�cate o<<o�,�,�fa ge�� �E.�,�=..a� APPLICATION FOR PLUMBING PERMIT � .
insure,or a certificate ot Workers'Compensation insurence,or . � •
a certifed copy there f( c.3800,t,ab.C.)
��-�a-3�-�o3ai�' COUNTYOFIOSANGELES ' - BUILDINGANDSAFETY=
olicy No. Company . � y � l ���s��/
—�__2
� Cerlif py is hereby furnished. ' FOR APPLICANTTO FILL IN(PHINT OR TYPE) BUILDING �
Cerlified copy is filed with the county builJing inspec ion
NUMBER FIXTURE OR ITEM • FEE A`DORESS p
�de `Imen� � � � � wqTER CLOSET � LOCAUTY ���t���J
Date Applicant NEAHEST
BATHTUB �! CHOSSST.
� CGRTIFICATE OF EXEMPTION FROM WORKERS'
. . COMPENSATION INSURANCE � SHOWER OWNER � �
MAIL �
, �(ThiS seCGOn need nOt be COmpleted if the wo7k invOWed LAVATORY � ADDRESS 1f 1 s.
by the permit is Por ofrc hundred dollazs (SI00)or less.) SiNK � � ° �
� CITY �i TEL.NO.f39�.�j U
1 certify that in the periormance nf the work tor which this DISNWASHER � �
permit is Isaued,I shali not employ any person In any manner � CONTRACTOR � /O @� � —
so as to become subject to the Workers'Compenaetion Laws. � CLOTHES WASHER � � qDDRE35 Q��, V �
Date Applicant � � """^`" aW
SWIMMING POOL RECEPTOR
NOT7CE TO APPLICANT:i(,afler making th8 CertiCcate af dTY - TEL.NO.'f'� � �
Fxemption, you shouid become subject to the Workers' LAWNSPRINK�ERSVSTEM Z
Compeneation provisions of the Labor Cnde,you must forih- STATE p�7,h LIC. �,/ —
with compiy with such provistons or this permit shali be WATER HEATER �i LICENSE NO. �!✓�'� CLA55 ��7h'
deemed revoked. � GAS SYSTEM�`OUTLETS �`� DISTRICT NO. PROCESSED BV
LICF.NSED CONTRACTOR5 DECLARATION � ��* p�
OUTLET$OVER
I hereby affirm that I am Iicensed under ptovisions of Chapter � 5 PE R SYSTEM O�f
9 (commencing with Section 7000)of Division 3 of the Busi- F�NA� VALIDATION
ness.and Protessions Code,and my license is in fuli force and DATE �G 2�/��/
effect. yO F I N AL
License Numher �//��Lic.Class � � BV G�/�[� '
Contractor � � Date ��02�'�
� I am exempt from the licensin¢requiremente as 1 am a PI3n check fee .
licensed architect or a registered professional engineer pLUM81NG PERMIT ISSUING FEE S �
acting In-my professionel caDacity(Section 7051, Bus• .
iness and ProCessions Code). � � TOTAL FEE �
Lic.or Reg.No. Date P1an chock applicant • �O 7 q��,
HOME OWN£R-BUI4DF.R DECLARpTION Name . ts� ���,�,�V
1 hereby afFrm that 1 em exempt from the Contrsctor S Addre�s r = e,7'�5 G
Litense Law for the fo�lowing reasan(Section.1091.5,Busi- City Tal.No.
ness and Professions Code): e s 7 7.��� �
� 1,as owner of the property,am ezciusively contracting . � -
with licensed contractors to construct the project O Q O e_2`�
� (Section 7044,Business and Yrofessions Code). .
CONSTRUCTION LENDING AGENCY
I hereby effirm thot there is a construt[ion lending agency
1 tor the performance of the work Por whlch this permit is .
�� i55ued(5ec.3097,Civ.C.).
LendePs Name �
1
'1 Lender's Address ,
1 I certify that I have read this applicalion and stete that the .
above information is corrcct.i agree to compty wilh all County SEE REV ERSE FOR ERPLANATORY LANGUAGE �
ordinances and State laws regulating Plumbing, and hereby - �
authorize repreuntatives of this County to enter upon the � �
'�aybJov�e-�mfe honed,va�y perly for inspection purposes.
//C�GGGLN' O��-ct�.w4iJ �"�—��
Signn[ure of Permittee ' Dete �
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