HomeMy WebLinkAbout0814A (4) WORKERS'COMPENSATIONDECLARATION �.-a•,- qPPLICATION FOR PLUMBING. PERMIT
I hereby affirm.that [ have e rertiticate of consent to self �cfi n�(z-so� �
tnsure,or a certiPicate of Workere'Compensation Insurance,or _ , .. . ��, ';
a certified cop thereof(Sec.3800 ab.CJ � ` �� ` � �
(D/0 ��3��/od v r�' �� COUNTY OF LOS ANGELES - BUILDiNG l�,ND S�T�
`Policy No. Company � � - � � � � � � � �
�"CCiLifled copy is hereby fumished. ' . . - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING '/�y
�
L� Certified topy it filed with th county building ins ction NUMBER FIXTURE OR ITEM • FEE '�`DORE55 O'y�/ f�!!�
de artment. � � � LOCALITY �
�Oate�L Applicant */. WATER CLOSET � NEAREST _ '
. � BATH TUB IY� CRO55 ST.
� ,CERTIFICATE OF EXEMPTION FRObf WORKF.RS'
. COMPENSATION INSURANCE SHOWER OWNER �,n �
LAVATORY � AD RESS �� y�pL¢C��✓/1i�*-U }
(This section need not be completed if the wark invohed 6
by tAe permit is [or one hundred dollars (5100)or less.) �
'� SINK �� CITY �y'y�Y/ TEL.NO�-}r fyJa OU ..
_ I cerlity that in Ihe pertormance of the work for which this �ISHWASHER ¢ -
permlt ls Issued,[shali not employ any person in any msnner � 0`"d CONTRACTOR �{�� Q� O .
so as to bccome subject to the Workers'Compensation Laws. CLOTHES WASHER F-
�Date - �- Applicant � - ADORESS 335Z �/�� U
SWIMMING POOL RECEPTOR � W
NOTICE TO APPLfCANT:If,after making this Certificate of CIT TEL.NO.��j..�G/ �
Exemption, you should become subject to�the Workers' � � LAWN SPRINKLER SYSTEM . �
Cnmpensation provislons ot[he La6or Codr,yo�musl forth• STA7E r-� Y .LIC. �_� _
with comply wlth such provisions or this permit shall be
WATER HEATER �/ LICENSE NO. �7y✓m O CLASS
�deemed revoked. � GAS SYSTEM b OU7LETS � DISTRICT NO. � PROCESSED BY .
LICENSEU CONTRACTORS DECLARATION OUT�ETS OVER ,
I hereby affirm that I am licenaed under provisions of Chapter 5 PER SYS7EM /��'
9(commencing with Section 7000)of Division 3 of the Buab � � �- � FINAL �/ � V LIDATION
ness and Rotessions CoJe,and my license is in Cull force and DATE lU���/
e((ect. - � _ . .. . . . .
License Number` �9�� Lic.C1ass �� � gy��i}� � :
P. Q �
CoMractor���Lt4':� Date,���o� '
� 1 sm exempt trom the censine requirements as I am a Plan cheCk fE2
licensed architect or a registered D�ofessional engineer p�UMBING PERMIT ISSUING FEE S � � �
acting in my,professional cepacitY(Section 7051. Bus• - ,
inus and Professions Code). . TpTAL FEE � �
Lic.or Reg.No. Date Plan check applteani .
HOhtE OWNSR-BUILDER DECLARATfON Name � � `��1 ���
i here6y afCrm that 1 am exempt from ihe Contractor's Addrasa � � � �+` •` �
License Law tot the following reason (Section 7031.5,Busi• . City Tal.No. - - - -
ness and Professions Code): .� ���7 7 �Q
� T,as owner of•the property,em exclusively.contracting �� �
with Iicensed contractors to construct the project . • ^.n']�•�`�:�
(Section 7044,Business and Professions Code). . . .
CONSTRUCTION LENDING AGENCY ��r'O�_�z
I herehy af�rm that there is a conshuction lend[ng agency � �
for fhe performance of the work for which this permit is , � � . . �
issued(Sec.3097,Civ.CJ. � � �
Lender's Name
LendePs Address � .
I certify that 1 have read this application and state that the � � . .
above intormation is carrect.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
1 authorize representatives of this County to enter upon the
above-mentio ed prop y for Inspectton purposes. � - � � � � - �
���'� d,eL/LIn.G(/ �`�'-��
Siynature of Permittee Date � � - .
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