HomeMy WebLinkAbout0795A wurc�ceKS'COMPENSAT[ON DEC6ARATION vusow �
� 1 hlreby af��m �ha� I have a certiCcate ofconsent toself �e.,,�P-.o, APPLICATIDN FOR PLUMBING PERMIT
insuro,ar a certificHe o(Workers'Compensation Insurance,or �
a certified copy ther of(Sec.3800,L�b J , _
��✓" �G- ��-��Cy�G � COUNTYOFLOSANGELES ^'^^�•� •�--� BUILDiNGANDSAFETY� :
YolicyNo. Company ����� ��,s� � f
� CertiRed copy is here6y furnish . FOR APPLICANT TO FIIL IN fPRINT OR TVPE) BUILDING -� i
NUM R FIXTURE OR ITEM • FEE ADDRESS pz0 Q
� Certified copy ia fiied with th c unty building inaDectio � {
�ie artmenC.. �� �l wATER CLOSET ,�.�I LOCALITV
Date 'z-Y AOD���ant "�"`-��� v V NEARES7
� BATH TUB GZ.F/ CROSS ST.
� CERTIFICATE OF EXEMP710N FROM WORKERS'
COMPENSATION INSURANCE � SHOWER �J OWNER � � __-.-
LAVATORV
MAII.
�(This eecNon��need"not be eompleted if the work imolved � ADDHESS �� � �-�-`� `Y .
by the permit is tm one hundred dollara(S1D0)or less.) SINK O�-d y �-
CITV �j� TEL.NO jQ,��JO O .
I certify that in the performence of the work for which ihls DISHWASHER �
— permit it insued,1 ehali not employ any person in eny manner �� CONTRACTOR ��_ �1i e � �� ¢
so as to become su6ject to the Workers'ComD6naeHon Laws. CIOTHE3 wASHER �� qDORE55 ����zi ��-�� �! � '
Dete Applicent SWIMMING POOI RECEPTOR V ,
NOTICE 70 APPLICANT:[f,afler making th(s Certiticate nf CITV ��,� TEL.NO.�dt_�ppf a '
Exemplion, you should become subject to the Workers' LAWNSVRINKLERSVSTEM STATE y 7 ` LIC. �
Compensation pmvisions of fhe Lebor Code,you muet forth• G� LICENSE NO. /�✓G�C CLASS �-�� � �
witli comply with such provisions or this permit shall be WATER HEA7ER
deemed revoked. � � / GAS SVSTEM tj OUTLETS „,/ DISTRICT/f�O. PqOCESSEq QY .
LiCENSED CONTRACTORS DECLARATION � 6`V O\ X�
OUTLETSOVER
[here6y affirm that I am licensed under pmvisions of ChaDter � 5 PE R SVSTEM �
9 (commencfng with Sectfon 7000)of Division 3 of the Ausi- - � F�NA� VALIDATION �
ness and Professions Code,and my Iicense is in full force and DATE l� � , . �
etfect. FINAL
Licenae Number77/�//� /�-�'��.�_��Ua Class �-� BY �
Contractor_Lf��Date� "�� �/ � . , .
� 1 am exempt from the'licensing requ�rements as i am a Plen check fee
iicensed architect or a registered profeuional entineer p�UMBING VERMIT ISSUING fEE 5
acttng in my�professional capacity(Seetlon 7051,Bus- � �
ineu and Wofessionc Code). TOTAL FEE ��' �TJ � �
Lic,or Reg.No. Date Plen check applicant
?n74.5A
HOME ON'NER•BUILDER DECLARATION Name � .
. .. n• • e •��J
1 hereby affirm that I am exempt from tfie Contractor's Aearen ' •
Litense Law tor the foliowing reason(Section.7031.5.RLLsi- �ity Tel.No. 't• •7 3 5 C
ness and Rofessions Code):
� i,as owner of the propeny,am exduaively contractine � . � • •�i'�'S�v� �
with licenud contnctors to construct the project t�
(Section 7044,Businesa and Professions Code). O U O C'-2�
WNSTRUCiION LENDING AGENCY . .
1 hereby affirm Ihat there is a conslruc�lon lending a¢ency
for the performance oP the work for which this permit is � ,
issued(Sec.3097,Civ.C.).
Lender's Name
Lender's Address -
I tertify that 1 heve read this application end state Ihat ihe
above informetion is correct.I agree to comply with atl County SEE REV ERSE FOR£XPLANATORY LANGUACE
ordinances and State laws regulating Plumbing, and hereby � .
authorize representatives ot this County to enter upon the
above-mentioned pro erty for inspection purposes. -
�1a�.�a��,��—a--e��
� Signa[ure of Permittee , Date �
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