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
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