HomeMy WebLinkAbout1473A (8) E ;
��ORKERS'COMPENSATIONDECLARATION �a��aw � APPLICATION FOR PLUMBING PERMIT �
I herehy affirm that I have a'certificate of consent to self �� ce an(r�o �
fnsure,ot a certiCcate of Workers'Compensation insurance,ot . � � � ' �
a certified copy ihereof(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
ror�Y�35853gR��mpany lns. Co. W.es.t
� Certifed copY is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILD�NG � � �
NUMBER FIXTURE Ofl ITEM �• FEE ADDRESS 2�LO Mo n i e U
Certifed�copy is fiied with e cou y 'di inspeclion � LOCaLITY
�� � t' � WATERCLOSET � D 1,7111011fI 88Y � � �
Date pplicant NEAHEST �
� � • BATHTUB CROSSST. �
CERTIFICATE OF EREMPTION FROM WOR .
- COMPHNSATION[NSURANCE SHOWER � � OWNER � �
- LAVATORV MAIL . .
(This section need not 6e completed it the work involYed � � -� ADDRESS } �
by the pe:mit is for one hund:ed doilazs (5100)or less.) siNK a
. CITY TEL.NO$6��263 0
— I certity that in the performance of the work for which thts DISHWASHER V .
permit is issued,I shall not employ any person In any manner CONTRACTOR 'Efl V 1,I'OflRlflll C8� E(1 .
so as to become subject to the Workets'Compensation La�vs. CLOTHES WASHER - � '
Date Applicant ADDR���. N. .Po��l�a'�r . o .
NOTICE TO APPLICANT:If,after making this Certiticate of' SWIMMING POOI RECEPTOR CITY n e TEL.NOG 39�S�L S� W -
Exen7ption, you Should become subject to the Wotkers' LAWNSPRINKLERSVSTEM Ora. 9 n- .,
Compensallon provlslons of the Labor Code,you must forih- WATER HEATER � L CENSE NO. � ��4$ CLASS C44 Z �
with comply with such provisions or this permit shall 6e — .
deemed revoked. � . � GAS SVSTEM OUTLETS DISTRICT NO. PR ESSED BY .
LTCENSED�CONTRACTORS DECLARATION OUTLETS OVER- rO �
I hereby affirm that 1 am licensed under provisions�ot Chapter 5 PER SYSTEM .
9(commencing with Section 7000)of Division 3 of the Busl• � FINAL Z ��//i�/ VALIDATION
ness and Protescions Cnde,and my Iicense is in full force and 1 S o 1 a r pomes f i c� S� a � O C) OATE j/%
effect. S Y�S,t BRl � � �
FINAL����
License Numher ;1 q 1 4 g� Lic.Class C 4� 1. By � '�
ContractorEn v. En g. Date 2�2 8 Y .
� I am exempt from ihe Iicensing requirements as[am a Pian eheck fee �
licensed ar[hitect or a reglstered professional engIneer pLUMBiNG PERMIT ISSUING FEE E v � .
acting in my profe5sional capacity(Section 7051,Bus- �
iness and Professions Code). � TOTAI FEE - jf � �
Lic.or Reg.No. Date Plen check eppllcant �,
-�14Z3A .
HOD1E OWNER-BUILDER DECLARAT(ON Nama . • �' - - �
. . . . �• • •�.
1 here6y affirm that I am exempt from the Contractor's Address � ' . .
License Law tor ihe tollowing reasan(Section.7031.5,Busi• CitV Tol.No. - � � � . . .� • •3 Q 5 0 .
nessand Profssions Code):: � � �3 Q J'Q� �.
� I,as owner of the property,am exdusively contracting
with licensed contractors to construct the project 0'Z� Q—$(G '
(Section 7044,Business and Professions Code). . . . . -, -
i
CONSTRUCTION LENDINC ACENCY . � � -
I hereby affrm that them is a construction lending agency '
�for the perforntence of the work for which this permit is � . - _ . . ,
issued(Sec.3097,Civ.C.). - . � � -
Lender's Name - �
Lrnder's Addras - � �
I certify that I have read this apptication and state that the - � ' � � � +
above intormation is mrrcct.1 agree to comply with all Caunty . SEE REV ERSE FOR EXPLANATORY LANGUAGE � � -�" " �
ordinances a d ate I s regulating Piumbing, and hereby . �
auf ze re ese tatrve of this County to enter uDon ihe '
abo e- enti p r for inspection purpases. � � � - .
2��
Signature of Permi[tee - Date . , � �
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