HomeMy WebLinkAbout0802A WORKFRS'COMPENSATIONDECLARATION ,�•••,- � qPPLICATION FOR PLUMBING PERMIT � {j
I hereby affvm that.l heve a'certificate of consent to self ce�v(z-eo
insure,or e certificate ot Workers'Compensation Insurence,or . � �. � �� I I
certifie copy thercof(Sea 3B�pyEab.C.) � .._.
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��_���sf�i-�p,?jd � COUNTVOFLOSANGELES BUILDII�GANDSAFETI7.
PoltcY No. CompanY D��<�— �.�
� Cert copy is hereby furnished. FOR APPLICANT TO FII.L IN(pRINT OR TVPE) BUILDING. i l(� . �
� ADDRESS O�� �� 7
Certified copy is filed with the county building inspectio NUM9EH FIX7URE OH I7EM � FEE
�lepartmen � - . LOCA�ITY��u�� �J
Date.��ApPlicant WATER CLOSET � NEAREST �
� BATH TUB � CFi053 ST.
CERTIFIGTE OF EXEMPTION FROM WOR RS' �
COMPENSATIONiNSURANCE . � SHOWEA - � � OWNER L�/
LAVATORY MAR � .
(This aection need not 6e�completed ii the work invOlved AO�RESS c ws� �
by the permit Is fm oM Aundred dOtlara (f100)or less.) SINK . d'U CITY � r y� TEL.NO.�'y9l ` O _
1 certity thet in the performance of the work for which this DISHWASHER /a� V
— permit is iscued,1 shall not employ any peraon in eny manner , CONTRACTOR �� ��p �
so as lo become subject to the Workers'Compensetion Lawc. CLOTHES WA3HER p o qDORE35 �
Dale ApD��cant /���� � � U
SWIMMING POOL RECEPTOR W
`� NOTICE 70 APPLICANT:If,after meking this Certificate ot CITV TEL.N0.9�j�/fyp� � .
Exemption, ynu shouid become subject to the Workers' LAWNSPRINKLERSVSTEM 37ATE v LIC. •n
Compensafion provisiona of the Labor Code,you muat fnrth- / LICENSE NO. � O CLASS �` 'Z
with complY M'�1h such provisions or this pe�mit ahall be WATER F4EATER /� —
deemed revoked. � - � GAS SVSTEM OUTLETS � �d' DISTFICT NO. ROCESSED BY
�� LICENSED CONTRACTORS DECLARATiON OUT�ETS OVEft
I here6y etfrcm that 1 am licensed under provisions of Chapter 5 PER SYSTEM � 4�d
9(commencing with Section 7000)of Division 3 nf the Busi• � � FINAL T ON � �
nesa and Yrofeasions Code,and my Iicense is in full force and Da7E �C7�—/S��f
effect. � ' �
Licenu Number �Lic.Class � �� BV AL �Om ,
� �����
Contrector Date� �
� 1�am exempt from the 1 ensing requiremente as I am a P�8I1 ChOCk,fB¢ '--� � � '
licensed architect or a reelatered professional engineer p�UMBING PERMIT ISSUING FEE S fd
acHng in my protessional eapacity(Section 7051.Hus- �
iness and Profesxians Code). TOTAL FEE � Z� � _ .
Lic,or Reg.No. Date Plan eh�ck eppticant �o a a 2 n
Neme . . • •�. e� .
HOME OWNER•BUILDER DECLARATION '
1 hereby affvm thaf I am ezempt from the Contrector's Add�� `�e e']�j(;
Licrose Law for the fotiowing reason (Section 7031.5, 8nsi- ���y Tel.No. -T r
ness end Profasions Code): � • ''�7�"n-
� i,aa owner of the properry,am exciusively contrecting 0�a.O n�2�
with Iicenaed wntractors to construct the project . "
(Section 7044,Business and Yrotessions Code). .
CONSTRUCTION LENDING ACENCY , , - � _
1 hereby a(firm thet there is a construction iending agency -,___
for the perfnrmance of the work for which this permit is -
isaucd(Sec.3097,Ctv.C.). .
Lender's Name
Lender's Addreu �
1 certify that I have read this aDp�ication and state thet lhe '
above information is correct.1 agree to tomply with all County SEE REVERSE FOR E7CPLANATORY LANGUAGE
ordinanCes and State laws (egulating Viumbing, and hereby �
aulhorize representatives of this County to enter upon the .
above-mentioned�p/roperty tor inapection purposes. �
�a�,7.,..• �(tu.�..;�� h�— •2 —�'/
Signature of ermittee ' Date -
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