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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 � � - . __- � c _ � v � Gl � p Z -- " "� a D G � N N � v v _ - " `LZ Z i' `n S '[ G -� S D v _ . 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