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HomeMy WebLinkAbout0812A •WORKERS'COMPENSATiON DECLARATION �usa• ^ 1 hereby affirm �ha� � he�e a certiFcate of consePt to selT �e.�„=-.o, A P P L I C A T I Q N F O R P L U M�B I N G P E R M I T U insure,or a certificate ot Workers'Compensatian Insurance,or _ . ��, , i ��certined co}y/.e�hf reof(sec.seo Lab.CJ COUNTY OF LOS ANGELES BUI LO�NG AND SAFETY', G`✓'�Y-�O.�od� � t yc No. ComDany �� - �TJ' �� � Certi � �rnpy is hereby furnished. � FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILD�NG - � ADOHESS ,�� Ll Certified copy is filEd wtth the counry building Inspe i n NUMBEF ' FIXfURE OR I7'EM • FEE � . �de artmen}. WATER CLOSET � LOCAUTY Dete 'y`��� ADP���ant ' � �' NEAREST � �� � BATH TUB CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' � `� � �. COMPENSATIONINSURANCE SHOWER � � � OWNER I.AVATORV MAIL (This section need not be comple[ed if lhe wark invohed O'� qoone33 y ' arc� � by tAe permit is [or one hundred dollara (5100)or less.) ' SINK '�' �- � Oy CITY � � �j f TEL.NO.��q���� O I certity that tn the per(ormance�of the work for whlch this � DISHWASHER aE' � V — pe[mit is isaUed,i shell not emyloy eny petson fn any mennet CONTRACTOR �� Q so as lo become subject to the Workers'ComDeneation Laws. CLOTHES WASHER ADDRE53!3'���� .�,v_� O � Date Applicant SWIMMING POOL RECEPTOR w NOTICE TO APPLICANT:If,after making this�Certiflcate o[ CITY TEL.NO.���"pq�i� 0. ExemDtion, you should bacome subject to the Workers' LAWN SGRiNKLER SVS7EM � STaTE y �IC. N Compensation provisions of the Labor Code,Y�u must[orth- � yyqTER HEATER LICENSE NO. J �.��✓� CLASS ��– z with comply with auch provisior� or this permit shall be deemed revoked. � � � � �-� �� GAS SYSTEM� OUTLETS .,1 DISTRICT NO. PROCE5SED BV LICFNSED CONTRACTORS DECLARATION ��� � OUTLETS OVER I hereby etCvm thet l�am ticensed under provisions of Chepter 5 PER SYSTEM i°Y� 9(commencing with Section 7000)of Division 3 0(the Busi• � FINAL VALIDATION ness and Pro[essions Code,and my license is in full force and DATE lU�$�� effect. /yp��f �_�j FINAL � License Number�4 Lic.Class gy � � � Contnctor��._7.Date �—��� � � � I am ezempt from the licensing requirements as 1 am a Plan check fee �icensed architect or a teqistered profeuional engineer pLUMBING PERMIT ISSUING FEE S v acting{n my professional capatity(Sec[ion 7051, Hu+- CJ � inas and Rofeuinns Code). TOTAL FEE ' � Lic.or Reg.No. Date Plan check applicant � . . . . "���'�,�� � . HOMG OWNER•BUILDER DECLARATION Name � . }• •. •� I hereby aff'vm that I am ezempt [rom the Contractor's Addreas ' - �� License Law tor the following reason(Section 7031.5.Buai- Cicy TaL No. � �� ��'7 7��G ness and Professions Code): . � I,as owner of the property,am exclusively contractin� � '�d 7 7'�?`' with Ilcensed contrectors to construct the ptoJect � �, � -��O O i�� - (Section 7004,Business and Professions Cade). . _ , � _ _ . CONSTRUCT[ON LENDING AGENCY � , . I hereby affirm that there is a construction Iendina agency � � � for the per(ormance of the work for which this permit is � issued(Sec.3097,Civ.C.). "' � Lender's Name - LendePs Address � � I rertiry that t.have read this applicallon and state ihat the � a6ove informallon is correct.[agree to comply with ail County SEE REVERSE POR EXPLANATORY LANGUAGE � � - ordinances and State laws regulating Piumbing, and hereby � authorize represent�tives of this County tn ente� upon ihe . 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