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 ��
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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 . "
above-mentioned p operty for inspection purposes. �
,�'1.l�'����_�.�--,�i
�ignature of Nermi[tee Date � �
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