HomeMy WebLinkAbout0793A wORKERS'COMPENSAT[ON DHCLARATION oewavw �
I here6y e�F�m that I have a'certlfipte of consent to self �ceu��z-ao) APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Cnmpensation[nsurance,or �
�cerhfied cop thereof(Sec.3800 Lab.C.)
��,-,�-/o.�od� �� COUNTY OF LOS ANGELES . BUILD NG ANDS FETY
icYNo. Company . . . � �� ����'�
� Cert' opy is hereby(urnished. FOA APPLICANT TO FILL IN(PRINT OR TVPE) BUIIDING �
ADDRESS� �
Ctttified copy is P�ed with the couniy building InsDecfion NUMBER FI%TURE OR ITEM • FEE n /
depertmen / /1 WATER CLOSET � LOCAUTY ����yr yxtv
Date APP��cant «��L � NEAR ST
BATH TUB � CROSS ST.
� CF.RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA710NINSURANCE SHOWER � Ol/ OWNER �� LM� r
MAIL
(This section nced�not be compkted if the xrork imolvCd � LAVATORY � �' qpDRE35 sC- 2l` ��-V
by the permit is [or om hundred dollats (SI00)or lees.) SINK � � a
. . CITY ,�� TEL.NO.�- �j.0 O .
I certi(y that[n the pttfnrmance ot the work for which this OISHWASHER V
— permit is issued,I shall not empioY eny Derson in any manner � � CONTRAC70R ,�t � �f �
so as to become SubfeCt t0 the Workets'Compenaetion Lews. CLOTHES WASHER � .,/ / O
. AODRESS ��.3'.�iZ� �IYG�a./�f• F-
Date Applicent � SWIMMING POOL RECEPTOR V
NOTICE TO APPUCANT:if,after making thls Certificale of CI7 - TEI.NO.-,��� aW
Exemplion, you should become su6ject to the Workers' LAWNSPRINKIERSY3TEM - / y y
Compensation provisions of the Labor Code,you muwt�orth- LI ENSE NO. ! ���0 C ASS ��� Z
with comply with such provisions or this permif ehal� be � WE+7ER HEATER /C./) —
deemed revoked. / GAS SVSTEM OUTLETS � DISTRIC�O. �FOCESS�BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
1 hereby aPfirm that I am licensed under provisions of Chapler f 5 PER SVSTEM
9(commencing wifh Section 7000)of Division 3 of the Buai• FINAL (�� LIQATION �
ne.ts and Profusions Code,and my iicense is in full force and DATE `(}/7'7 ,p' .
etfect.
/ /��r (/'� �f'�j FINAL ��
License Numbed �" Ltc.Clsss ` � BY �
Contracfor �Dafe��
� 1 am exempt from the censing requiremen[s as I am a Plan check fee _ .
licenaed architect or a registered profesaionel.engineer pLUMBING PERMIT ISSUING FEE$ � •
actine in my profe�sional cepacitY(Seetion 70i1,Bus- .
iness and Profesaions Code). � TOTAL FEE , � � �
Lic.or Reg.No. Date Plan chxk applicant i Q'�9.^F'� '
HOME OWNER-BUILDFR DECLARATION Nemo � H � �y�.��
1 hereby eft'Km that I am exempt from the Contractor's Addre�s ,1 � �%;� �
� License Law for the following reason(SectiOn 7031.5,Busl- City - Tel.No. U
ness and Professions Code): s 7�7� .
3'. O�
� I,as owner of the property,am exciusively contncting � � �
with licensed contractors to construct the Drqect 0 t„O n_7 3
(Section 7044,6usinus and Mofessions Code). . . . u
CONSTRUCTION LENDING AGENCY . � � .
1 hereby affirm that there is a'construction lending agency . �
for the performance of lhe work for which this permit is �
issued(Sec.3097,Civ.CJ. �
Lender's Name
Lender's Address
I certify ihat 1 have read this application and state that the
above information is correct.I aQree to compiy with ali County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laµ�s regulating Piumbing,and hereby ,
authorize represenfatives of this County to enter upon the
, ab e-menti ned pro rfy tor inspection purposes.� p / � �
f�(QlZ6t?�01dGLf�Y(.0 ��� �7 /
. S�gnature of Perminee Date
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