HomeMy WebLinkAbout0796A (4) WORKERS'COMPENSATION DECLARATION ts�enw
I hereAy.afCrm ihat 1 have e��e<<,��e«of consent to 5e�� �e.,,,=..o, A P P L I C A T I O N FO R P L U M B I N G P E R M I T {� .
insure,or a cerfificate ot Workers'Compensatian lnsurence,or '
a certi�ed eopy thereof(Sec.380u,Lab.CJ � � . L�
�i�i -�o-,�rd'^/03oty ���' COUNTY OF LOS ANGEIES "' -- ^ �- BUILDING ANDSAFETY,�
o�cy o. Company � q �3,sy��
� Certi ed copy is herehy furnished. � FOR AVPLICANT TO FILL IN(PRINT OR TYVE) q BUILDING �Ja y�
ADDRESS Ot / �
Certified copy is fited with the cnunty building ins ctlnn NUMBER FIXTURE OR ITEM � FEE
Date'e ",�'e�r Applicant ��� �. WATERCLOSET / � LOCALI7V�,�� �r�,�
NEARE3T
� BATH TUB� � p[�/ CROSS$T.
CERTIFICATE OF EXEMPTION FROM WORKF.RS'
-� COMPENSATION[NSllRANCE SHOWEq �� � OWNER pl
LAVATORV �J MA�� / f
(This section nced not be cOmpleted if the�work imolved �� P� ADDRESS ��l�p L�����v
by the permit is tm one hundred dollars (5100)or less.) �c. a
. SINK �� CITV �� �G'j� TEL.NOsr�-�/�d O
1 certify fhat in the pertormance of the wotk for which this � pISHWASHER /�/ V
- permit is iasuad,I shall not emD�aY any person in any menner CONTRACTOR �l�j
so as to become subject to the Workerc'Com ensation Lows. �
P � � CLOTHES WASHER �' ADORESS ��'3'�hZ .�� �
Date ppplicent SWIMMING POOL RECEPTOH U
'NOTICF:TO APPLICANT�It,aRer making this Certificate of CI7Y TEI.NO. _�0 f W
ExemD��on, you sh0uld become subje[t to the Workers' LAWN SVRINKLEH SVSTEM STATE �1 LIC, �
N
Compensalion provisions of the Labor Code,ynu must forth- LICENSE NO. �7/✓�� CLASS �`� Z
wilh comply avith such provisions or fhis permit shall be l WATER HEATER �l�l —
deemed revoked. DISTRICT NO. ROCESSE Y
/ GAS SYSTEM 5 OUTLETS �.�/ ,�
LTCENSED CONTRAC'TORS DECLARATION OUTLETS OVEP
I hereby at£uie that I am licensed under provisions of Chapter 5 PER SYSTEM A`d '
9(mmmencing with Section 7000)of Divisbn J of the Ausi• - � FINAL �� VALIDATiON
ness and Professions CoJe,and my license is in full force and DATE lv �-��
effecL r /� �
Licens<Number �u��LiaClass v � FINAL � ,
�� p` av r7N, l—.
Contractor���Date .�/
� 1 am exempt from the hcensing?equirementn aa I am a Plan check fee �
iicensed architect or a teeiatercd profeuional engineer �pLUMBING�ERMIT ISSUING FEE S a �
acting in my professional capecity(Section 7051,Bus- �:(;7 Q,Ei 4J
iness and Protessions Code). TOTAL FEE �J � :
LiC.or Rej{.No. Date Plan chack epplicant � � � �ti 7 7•`r�'C
HOMG OWNER•BUILDER DECLARATION Name - '' ` "7 7•'�<� '
1 hereby affvm that 1 am exempt from the Contraetor's AdOreaa� . � O�C�.�+`Z J
Li[ense Law for the foilowing reason (Sectinn,7031.5,Bu<I- C�ry � - Tel.No. � ,
ness and Protessions Code):
� 1,as owner of the pro0erty,am exclusively contracting - �
with licrnsed contracfors to construct the projett �
(SeCtion 7040,Business and Pro(euions Code).
CONSTRUCTION LENDING AGENCY '
I hereby afCrm that there is a construction lending agency .
for the performance of the work for which Ihis permit ls . � .
issued(Sec.3097,Civ.CJ. . - �
Lender's Name
Lender's Address
�I
, 1 cerlify that t have read Ihis application and state that Ihe
- above informetion is correct.I agroe to comply with all County SEE REVERSE rOR EXPLANATORY LANCUAGE
' ordinantts and State laws regulating Plumbing, and haeby ,
IaWhorize representatives of Ihis County to enter uDon the . �
bave-menlioned property tor inspectian purposes. � � .
CJ
i ,,,,.wrn�;<.• �l-�-d�/
gnaturoof ermittee ' llate .
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