HomeMy WebLinkAbout0813A WORKERS'COMPENSAT[ONDECLARATION �1�taw
1 hereby ef�-um �he� � he�e a'certificate o<<o��<<o self �e.�,�P-.o, �APPLICATtON FOR PLUMBING PERMIT �
insute,or a ccrti£cate of Workers'Compensation Insurance,or , . . - � � . ' `, , -+ '
a certified copy thereof(Sec.3&00 Lab.C � - � �� '
�e��a.��ftp^!a 3ad� COUNTY OF LOS ANGELES � '� "BUILDING ANDSAFETY-
�Policy No. Company - � � � �'�S� �
❑ CertifieA copy is hereby Pornished. , FOR APPUCANT TO FILL IN IPRINT OR TYPE1 - BUILOING�O� r �P ' � ,/��
� ADDRESS J iC"i�C.
Certified copy ia Ried with the county building inspection NUMBER FIXTURE OR ITEM • FEE �
� de art ent � LOCALITY
�� � �. WATER CLOSET �J �
Date ApP��ccut NEAREST
� � , BATH TUB p-� CROSS ST. -
� - CERTIFICATE OF EREMP710N FROM WORKGRS' � �
, - COMPENSAT[ON iNSURANCE �. SHOWER � � OWNER �lG
MAI L
(This sxtion need not be compteted if the wurk involved �AVATORY qDORE$S�� � 6}7.
by the permit is trn one hundred dollars (S100)or less.) . .
. . . . SINK � CITV �_ ��'sI TEL.NO�-�9 �JO O
— I certify that in the performance of the work for which this � DISHWASHER � � �� � �
permit is issued,I shall not employ any person in any manne[ CONTRAC70R O �
so as to become subject to the Workers'Compensstion Lews. CLOTHES WASMER .G� �3�_�. � U
ADDRESS
Date � Applicant W
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT:If,after making thfs Certificate of dTV TEL.N09�at/�/ � �
�Exemption, you should become subject to the Workers' LAWN SPRINKLEp SVSTEM z
Compensation provisions o[the Labor Code,you must forth• STATE LiC. �_z/ _
WATER HEATER IICENSE NO. � 9.I�p T CLASS �x�
with comply wtth such provisions or this permit shall be � m''�
deemed revoked. � . �� � GAS SYSTEM�OUTLETS �ISTRICT NO._ - PROCESSED BV ;
/)
LICENSED CONTRACTORS DECLARATION OUTLE75 OVER � �%1
� I hereby ef£vm that I am licensed under provisions of Chapter � 5 PER SYSTEM ��B
9 (commencing with Section 7000)of Division 3 ot the Bmi- � FINAL r D �,ION .
ness end Wotessione Code,and my license is in full force and OATE �U ly .
effect. y ' -�y � - .
/9f�4 ��•� . . . FINAL '
License Num6er Lic.Class gy
f
Contraato_d�� Date ' � � .
' � I am exempt trom t ticensing requ'vements as t sm a P�an check fee
licensed arehittct or a registered professionsl engineer pLUMBING PERMIT ISSUING FEE S � �
acting fn my profeasional capatiry(SeMbn 7051,Bui•. -
iness and Professions Code). . TOTAL FEE
Lic.or Reg.No. Date Plan check applicent
HOME OWNER-BUILDER DECLARATION Name � , - �
I here6y affirm that I am exempt trom the Contnctor's Addrms '
License Law for the following reason(Section.7031.5,Busi- City - Te�.No. � � �
`:C���'';{�i
ness and Professions Code): . •
� i,as owner oP the property,am ezdusivety cootading � - �!� • ��•�j
with llcenaed contractors to construct the proJect - �
(Section 7044,Business and Professions Cade). . . . � � �:� • •'j�,S Q �
CONSTRUCT[ON LENDING AGENCY . , ,'J j.S(;? ,
I hereby a[firm that there is a conatruction Iendin;agency � �
for the per(ormence of the work for which this permit is . ���,O�_�3.
issued(Sea 3097,Civ.C.). ' � �
LendePs Name
Lender's Address .
1 certify that I have read this appiication and state that the � �
above intormation is correct.1 aQree to comply with atl County . SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumhing, and here6y � �
authorize repreuntatives ot this County to enter upon the
above-mentioned prop for inspection purp es. -
/.G/D/�� R.G/��[.t�l� /��/.�� . . � - .
1'�Signature of Permittee Date
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