HomeMy WebLinkAbout0917A (4) WORKGRS'COMPENSATfON DECLARATION nwww
reby affirm that I have a'[ertificate of consent to seif � cs.,,,=..o, APPLICATION FOR� PLUMBING PERMIT �
'e,or a certificale of Workers'Compensetlon Insurance,or , . .
�tified coOY thereoi(Sec.3800,Lab.C.)
s , COUNTY OF LOS ANGELES BUILDiNG AND SAFETY
:y No. Company � �
�� �Certified copy is hereby furnished. . FOR APPLICANT TO FILL IN(PFINT OH TYPE) BUILDING �1 �
AODRESS �
� ���Certified copy is filed with the county 6uilding inapection NUMBER FI%"R1RE OR ITEM � FEE
Q �de artment. LDCAUTV �,�
P WATEq CIOSET
e � Applicant N AREST �
9 �. � BATH TUB CFOSS ST. '
e'CERTIFICA7E OF EXEMPTION FROM WORKERS' ,
� : COMPENSATION INSURANCE SHOWER OWNER _
MAI L
�� { SeCtiOn need not be CORIplettd i�the wOfk InvOlved LAVATORV ADDHE93 a
n he permit is for one hundred dolisxs (5100)or lesa.) SINK CITv TEL.NO.�y 6`f O
�tify that in Ihe pertormance e wnrkifC�w 'h this DISHWASHER �
,1�,J CONTRACTOR �
d it is issued,[shall not empl a erso.. a anner G1Lt/tJL � O
.to become subject lo the r r o(ins n LaNs. CLOTHES WASHER . V �
ADDRESS
AP�11C°^t r �� SWIMMING POOL RECEPTOR W
f� CITY TEL.NO. y
es �CE 70 APPLICANT:if,after ma n this Certi cate of .
iption, you should become suA c to the orkers' � �� LAWN SPRINKLER SVSTEM STATE LIC. z '
fs �ensntion pro�isions of the Labor de,you muat fotth• LICENSE NO. CLASS �
�e comply with such provisions or�this permit shail be WqTER HEATER
f ed revoked. � � GAS SVSTEM OUTLETS + O�l DISTRICT NO. P CESSED BV
n � LICENSED CONTRACTORS DECI.ARATION V -
1e , OUTLETS OVER 6/-«� .
by affirm that I am licensed under provisions of ChaDter 5 PER SVSTEM .
nmencing with Section 7000)nf Dieision 3 of the Busi- - � � - � F�NA� �" VALIDATION '
nd Rofessions Code,and my Iicense is in full force and DATE l l^� � �J� ,
FINAL �
-Number Lic.Cless BY � '
ctor Date
�am ezempt from the licensing requiremenls ae I am a Plan check fee �
- cenaed architect or a regislered profesaionai engineer pLUM81NG PERMIT ISSUING FEE y �(�
:ting in my protessional cepaciry (Section 7051, Bus- J
�ess and Profestions Code). TOTAL FEE ,�Q
Reg.No. Date Plan check applicent , �
HOMEOWNER-BOILDERDECLARATION Name � � ��
-by affvm that I am exempt�trom fhe ContractoPs Atldrys -^.p O,,']�
•Law for the foliow�ing reason (Section i031.i.Busi- CitY Tel.No.
��Protessions Code): . �*'.• • • •5 �
as owner o[the property,am exclusively conlncting � - . � e • � 2,cJ O -
th licensed contractors to tonslruct the project
ection 7044.Husiness and Profasions Code). � �1 2.Jr O�
CONSTRUCTION LENDING AGENCY �.
�y affirm that there is a construction lending agency (2�7—8'�
� performance ot the work for whfch this permit is . . �
Sec.3097,Civ.C.). � � �
's Name
s Address � - �
y that 1 have read this application and state Ihat the
iformetion is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUACE �
e�b���and Sta s re at g Plumbing, and hereby �
preseN tive of his ounty to enter upon the ' . �
� i d p perty fo i ection purpo e. �
� , �?��8
•.ture f ermittee - Date �
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