HomeMy WebLinkAbout1041A WORKGRS'COMPENSATION DGCLARATION o���aw � -
I hereby affrm tha� 1 have a certificate �r���,�,<<o,e�� ccm�z-ee� APPLICATION FOR PLUMBING PERMIT ..
insure,or a certificate of Workers'Compensation Insurance,or � -
u certifled copy thereof( e.3800,La6.CJ - � -
�/r-►�9 �� S� �,,_I �Q COUNTY OF LOS ANGELES BUILOING AND SAFETY
Yo11cy NbT� Company ��W�`'dt .
� CertiCed cop is hereby Curolshed. FOR APPLICANT TO FIIL IN(PRINT OR TYPE) BVILDING �7� j7^ _I a '
ADDqESS � r��'r��
ified Copy is filed with the count �Iding inspection NUMBER FIXTUNE OR ITEM � FEE � .
d ar en � WATER CLOSET LOCAUTY� �,�v� �
natel��b�Applicenf � NEAREST
. BATH TU8 CROSS ST. �
CERT[FICATE OP FXEMPTION FROM WORKERS' !_ /
. COMPENSATIONINSURANCE . SHOWER . OWNER �/ � [r0 �V
LAVATORV MAIL �A1��QNC�i�. �
('17iis section need not be complefed if the work involved AD�RESS
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by the permit is for one hundred dollazs(5100)or leu.) SINK CITY � oN� �TEL.NO. O
I certity that in the performance of the work fnr which this DISHWASHER V �
permit is issued,I shall nnt employ any perwn in any manner CONTRACTOR V S"�/� '
so as to Aecome subject to the Workers'Compensation L�ws. CLOTHES WASHER �
Date Applitent - ADDRE55���r � �,� t� ` O-
SWIMMING POOL RECEPTOR U �
NOTICE TO APPL(CANT:If,after making this Certificate of CITY �y..� T . .'7'� GjC�� W .
Exemption, you should become subject to the Workers' LAWNSPFINKLERSYSTEM STATE LIC. Q �
Compensation provisions of the Labor Code,you must forth- . LICENSE NO.�/S�3 CLaSS r,�l'C 2 �
with comply with such provisions or this permit�shell be WATER HEATER — ,
deemed revoked. GAS SYSTEM OUTLETS �ISTRICT NO. PiiOCESS B
LICENSED CONTRACTORS DECLARATION OUTLETS OVEH ���t7 1 —
I hereby a(frm Ihat I am licensed under provisions o(Che�ter 5 PER SYSTEM ,
9 (commencing with Section 7000)oI Divisian 3 of the Busi- O � � FINAL
ness and Professions Code,end my license is in lull force and L �� OATE�Z_'Z�'j;,. VALID �ON ,
effect. -- . � -
��IS� �I'� C�� FINA � .
License Numbe Lia Class BY �
Contracto(//G2/Y1�..V���Qf41e �����/o� . �
� 1 am exempt(rom the Iicensing requirements as i am a Plan cheek tee
licensed architect or a registered professional engineer pLUMBING PERMI715SUING FEE S �a
act3ng in my professional capacity (Sectian 7051,Bus-
ine^s and Professions Code). � TOTAL FEE � S�
Lic.or Reg.No. Date plen check appllcant �
fiDME OWNER•BUILDER DECLARATION Name - �
i hereby aCfirm that 1 am exempt from the Contractor's Add�ess
License Law for the following reason (Section 7031.5,Busi- Citv Te4 No. � � � .
ness and Professions Code):
� 1,es owner of the property,am exAusively tontracting � � � � ��
with licensed contractors to construct the project 2���a-� A
(Section 7044,Rusiness and Professions Code). - ,
CONSTRUCTION LENDINC Q(CENCY .- #_������� �S ..
1 hereby affirm that there is a constpfcl�on lending agency � . .� • •� ,L 5�
for the pertormance of the work ff�which ihis permit is . . . ,
issued(Sec.3097,Civ.C.). - � ' �� �,• ,
�ender's Name . � Z Jr O ci
LendePsAddrss � � .�2��b-8;1
1 certify that I have read this application and state that the
above information is rnrrect.1 agree to comply with all County SEP•,REVERSE FOR LXYLANATORY LANCUAGE �
ordinances and State la�vs regulating Pium6ing, and hereby .
uulhorize representatives of this Caunty to enter upon the �
aM1ove-ment�i e p�r/e y for inspection purposes. , � - �(
�'7 L�--�._... /r�-�/6 j� '
Signature of Perrnittee Date
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