HomeMy WebLinkAbout0794A (4) WORKERS'COMPENSATIONDECLARATION �••"�� , APPLICATION FOR PLUMBING PERMIT
I hereby afflrm that I have a'certlCcate of conset�l to ulf c��n(:ro �
insure,or a cettificste of Workers'Compensation Insurance,or � ,
a certiCed copy thereot(Sec.3800,Leb .)
��_��;.,��o-�-r. COUNTY OF LOS ANGELES •-- -� - -BUI4DING' ND SAFETY:,
olity No. Cnmpany � � ���'"-' � .(/ ����L� I
� Cer�fied copy is hereby futnished.�/ � � FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING - � +
NUMBER FIXTURE OR ITEM • FEE ADDRESS Q
� Certified copy is fiied with the county building inspec i � ` �
LOCALITY
�a' par� � .ApP11Cen � WATER CLOSET � NEAREST ���K�J
� � � BATH TUB CROSS SL �
.. CERTIFICATE OF EXEMPTION FROM WORRERS' '
COMPENSATION INSURANCE SHOWER OWNER ��j� -t;�t��
LAVATORV '. J MAIL ,
(This seMion need not be completed ii the work invalved l� ADORESS / 1 � e�e� a
by the pelmit is tor one hundrcd dollars(5100)or IeuJ g�NK ciTv TEL.NO. i9���� O �
1 certify that in the performence of the work for which thL� DISHWASHER �
permit is isaued,i shall not employ any perwn in any manner � / CONTRACTOR ��� �J� Q
sn as Io become subject lo the Workera'Compensation Lews. � CIOTFIES WASNER (y O-� ADDRESS��'��� ������ (~j
Uate - Appiicant ' ' � SWIMMING POOL RECEPTOR d .
NOTICE TO APPLICANT:f(,after making this Certificate of CI7Y TEL.NO. ���rp� y
Exemption, you should beCome Subject to the Wotkers' LAWNSPRINKLERSVSTEM - � - STATE LIC. /�' �/ Z -
Cnmpenaation prnvixions ot the La!ar Code,you must forYh- yyqTER HEATER LICEN3E NO. .�9� C�ASS v-�'C�
u�ith comply with such provisions or this permit shali be
deemed revnked.' GO.S SVSTEM OUTLET5 �/ �ISTRICT NO. ROCESSED V
LICENSED CONTRACTORS DECLARATION OUTLETS OVER �
I hereby a!(vm that I am licensed under provisions o[Chapter 5 PEH SYSTEM . �
9(commencing with Section 7000)of Division 3 of the Ausi- FINAL VALIDATION � '
ness and Rofessions Caie,ond my�icense Is in full force and DATE j0 7 �/ .
ePfett.
FINAL �,M
License Number � ��Lia Class,�� �� BY �/�(
Contractor u Date� ���� �. '
� I am exempt from th licencing requ�remems an�am a Plan check fee . _
ticensed architect or a rogittered professional engineer p�UM81NG PERMIT ISSVING FEE 5 �
acting in my Droteasional capacity(9ection 7051, Bus- -
iness and Profeasions Code). � TOTAL FEE � �
Lic,or Reg.No. � Date Plan theck epplicent . .
HOME OWNER-BUfL�ER DECLARATiON Nems � � `�,7 Q�1 A • �
1 hereby aff'vm that I am exempt fram the Contractor's Addrafs y . •. � �y
I.icense Law for the following reason(Section.7D31.5,Busi- ���y . . Tal.No. - � �� � �
ness and Profasions Code): i� . •7 7 5 Q �
� i,as owner of the property,am ezclusively contncting � � � - ,
with licensed contractoro tm m�etmct the pmjecl •7'],�.Q�,
(Sedion 7044,Businesa ond Professionc Code). . . � '
CONSTRUCTION LENDING AGENCY �O�C�O O`�`�' ;
t hereby affirm that there is a construction lending agency � . . �
for the performance of the work for which this permit is � .
issued(Sec.3097,Civ.C.). . � . '
Lender's Name �
Lender's Address � �
I certify that I have read this a0p���ation and state that the -
ebove information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws reguiating Plumbing, and hereby
authorize representatives of this County to enter upon the � �
� above-mentioned pr rty for inspection purposes. �
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-'Signature af Permittee Date J
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