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HomeMy WebLinkAbout1821A (11) WORKERS'COMPENSATIONDECLARATION - �aw�a♦ � - qpPLICATION FOR PLUMBING PERMIT {� . I here6y affirm that I have a'certfficate of mnsent to self ce an(rso � � Insure,or a certiflcete ot Workers'Com e allon Insurance,or � - � � �� . ' � I� a��e� e e �e P 3800,La - - " � , . . ���.� j �� COUNTY OF lOS ANGELES BU�LDiNG AND S FETY � k om any �'� ���`�0.�re � Certified copy ia hereby furn' e . -FOR A�PLICANT 70 FILL IN(PRINT OR TY�E) ' BUILDING �t�� Certlfied copy is filed wit [he c unty bu d' NUMBER FIXTURE OR ITEM • FEE A`DORE55 �a ys� F{f:. �l art t. IOCALITY Uete ^ plica WATER CLOSET NEAREST D D- - BATH TUB � . CROSS SL � ' � � CF.RTiFiCATE OP EXEMPTION TROM WORKF.RS' " COMPENSATtONINSURANCE SHOWER OWNER S .' ' � LAVATORY MAIL • (This sectlon need not be completed if the work invoWed qooRESS by the permit is for one hundred dotlers (5100)or less.) SINK CITY TEL. V I certlty that tn ihe performance of the work for which this D�SHWASHEP � permit is issued,1 shall not em Io an - COMTRACTOR � p y y person In any manner O so as to become subject to the Workers'Compensation Laws. CIOTHES WASHER ADORESS U Date Applicant SWIMMING POOL RECEPTOR a � NOTICE TO APPLICANT:If,after making this Certificate of CIT L_N tixetnp[ian, you should 6ecome SUbjeCt to the Workets' LAWN SPRINKLER SYSTEM � ST E LIC. � Cnmpensatinn provistons ot the Lafior Code,you must Porth- LICENSE NO. � �CL � with comply with such yrovisions or this permit shell be WATER HEATER � deemed revoked. � GAS SYSTEM OUTLETS DISTRICT NO. ,�,(�RO SSED BY LIC�NSED CONTRACTORS DECLARATION OUTLETS OVER . t V ���Iv(! � I hereby affirm that I am Iicensed under pr�visions of Chapter 5 PE R SYSTEM 9(commencing with Section 7000)of Divlsion 3 of ihe Busi- FINAL C) �� p� VALIDATION � ness and Protessinns Cnde,and my license is in fuil force and DATE � d effect. FINA `7 License Numher /� Lic.Class_� � gy L� . Contrecto� Date����5� � � � (am exempt from the licenstng requirements as I am a PIBn ChOCk fee � , licensed architect or a registered professionai engineer pLUMBING PERMIT ISSUING FEE S g� �acting in my Drofesatonal capacity(Section 7051,Bos- � inas and Rotessions Code). TOTAL FEE � I� S - - Lic.or Reg.No. Date Pla�check applicant � 1{OME OWNER-BUILDER DECLARATTON Name �� �+�.$2� A 1 hereby affirm that ! am exempt from the Contractor'S Add��' #• •�• •i�5 License Law for the following reason(Section 7031.5,Busi- City � Tel.No. � - � - � - � ness and Professions Code): . . ''1'� •�� (�5� � [,as owner of the property,am exdusiveiy contncting � ' - � � ' � � with licenud contractors to cons[ruct ihe project �\���j C�eCk`C��},t`\�� �-���� ��,�.� � �.rJ Q c=,o (Section 7044,Business and Prnfessions Code). . . � � -� � - - . . CONSTRUCTfON LGNOING AGENCY - O��Ce.�'�-������ ���� S�� ,.. O�,',,—$2 I hereby aCfrm thet there is a construction lending agency for the performance of the work for which this permit is .Q���`�,`�S� C���Q'$ �(`'�. , . . '� issued(Sec.3097,Civ.CJ. LendePs Name � Q��C S������ _ LendePs Address �l.� ��1`f P� � \ �� �0 I Certify that I have read�his application and sfate that Ihe ��{Q 1(��C�.Qrc3� ' . above inf atlon is correct. agree to mmpiy wilh all County �� � . , .. . ordinan s a d State la re uiati l bing, and hereby SEE REVERSE FOR GXY NATORY LANGUAGE �� autho ee re resentative of t is to en upon the . abov mentiuned prop ty n e purpas . . � � �� � . /��Y _ _ Signature of Permittee Date � �� c G1 D � Z � ''n .G-1 D C �1�c�n N � m � - �,^ `LZ Z. r � p � { � y 73 v .. � . 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