HomeMy WebLinkAbout1154A WORKERS'CO!.1PENSATIONUECLARATION ]6AO�TA '
hereby affirm that I have a'certiCcate �f�o,�e„< <o��� �E.�.,=-.o, APPLICATION FOR PLUNiB.ING PERtv11T �
isure,or a tertificate of Workers'Compensation Insurance,or . .
certified copy thereof(Sec.3800.Lab.C.) � ,
COUNTY OF LOS ANGELES BUILDING AND SAFETY
'olicy No. Company � . -
�CertiPed py is hereby turnl e FOR APPLICANT TO FILL IN(PRINT OR TVPE) BUILOING ` �/J � �
A��RESS �-� 9 S CQ.�Ls.t�
Certi ed opy is filed with o ty �1 i i sp tion NUMBER FIXTURE OR ITEM � FEE
'� a . WATER CLOSET LOCALiTY
Date Applicant NEAREST
BATH TVB CRO55 ST. �
CERTI'fCAT60F EXEMPTION PROM WORKERS' - �
COS�IPGNSATION iNSIIRANCE SHOWER OWNER �
I.AVATORY MAIL . .
(This section need not be completed if the work involved noortEss }
by the permit is for one hund�ed dollsrs (5100)or IessJ siNK a
CITY TEL.NO. �g�y �
I certity that in the performance ot ihe work for which ihis DISHWASHER V
permit is issued,I Shall not employ any person in any manner CONTRACTOR
so as to become subject to ihe K'orkers'Compens�tion Laws. CLOTHES WASHER � � �
ADDRESS O
Da[e Applicant SWIMMING POOL RECEPTOR � � U .
NOTIC&TO APPLICANT:If,after making this Certificate ot CITY TEL.NO ��Q W
' Exemption, you should 6ecome subject to the Wnrkers' LAWN SPRINK�ER SVSTEM �'
STATE IIC. Ul
� Compensntion provisions of the Labnr Code,you must forth• LICENSE NO. I CLASS ��j li '�-
with comply with such provisions or this permit shall be WATER HEATER —
deemed revoked. � - � GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY
� LICENSED CONTRACTORS DECLARA710N O 1����.o-C�
� OUTLETS OVER �
I hereby aifirm Ihat 1 am licensed undet provisions ot Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 ot the Busi- FINAL VALIDATION
:ness and Professions Code,end my Ilcense Is in full force and OATE ��+—&�
� etCect. . . .
�.�^ Z FIN
- License Number�7L Cic.Class J BY � -
���erfa��r TALL[R° ' nate ' N O�O..O� �/(W.,Q �— -�—��—�
2Q�AST GR.hND A F��t�� Plan check fee
1Rqi-fJ�e AS g- ensing rrquiroment as I am a
,'+R�-Ciitfh4eFk�c.'t��aP�F�registered Drofessiona� engineer pLUM81NG PERMIT ISSUING FEE E
acting in my profeasional capecity (Section 7051,Bus-
iness and Rotessions Code). � TOTAL FEE - �O�
PAClFIC INSTA CERS, ING. 4 1 i 54 A
Lic.or Res.No. Plen oheck epplicent -
. 1��TVE U� #. . . . .5
fiOD1E O\VlY�1.IEIrG�j?�(1;�(�j��Q Neme � �
Addrets �y.� • • � 2'S� -
I here6y affirm lhat I am exempt from the Contractor's i
License La�v tor 1he tollowing reasan(Section.7031.5,Busi- City Tel.No. � � � ���������� • • � 2.rJ�c=j
ness and I?ofessions Code): � r �
� I,�s�wner af the property,am exclusively contracting � � � � �����, �1 2 2 9—81
with licensed conhactors to construct Ihe praject . �� �
(Section 7044,8usiness and Pro[essions Code). /'�a� � �
CONSTRUCT[ON LENDING AGENCY " ��Av . � � �- - � � �
1 hereby affirm that there is a construction lending agency �
for tht performance of the work for which this permit is ' _
Issued(Sec.3097,Civ.C.).
Lender's Nsme
Lender's Address � �
I certify t I have r t i app�ication and State that Ihe -
above i ma ion is rr .I ree to comply with all C nty . .
ordin c an a la e lating Plumbing and reby SEti REVERSE FOR EXPLANATORY LANGUAGE �
authr iz rep s rt ves of tlis County fo en er up i the � �
abo��- ntio e r e fo s0ection purpose. - �
I Sig� ture of ermitcee Dat � .
/
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