HomeMy WebLinkAbout0811A (4) WORKERS'COMPENSATIONDECLARATION ���sow � . APPLICATION FOR PLUMBING PERMIT /7
[ hereby affirm that 1 have a certiflcate of consent to seif �g���(z-ao y' -
insure,or a certificate o}Workers'Compensation Insurante,or � �' ', ��
a certifie copy hereof(Sec.3500,Lab.CJ � . - � - � U �
(�� -�D- �8�-�0 3 a�Y�' � COUNTY OF lOS ANGE LES •BUILOytst�G AND SAFETY�.
o�cy o. ompany L � p�I�-'F�i � �
� Certified copy B hereby furnished. �' FOR APPLICANT TO FILL IN(PRINT OR TYPE) pDDRESS �d (OJ�' Q�.�J
ertified copy is filed with Ihe county building inapection NUMBER FIXTURE OR ITEM • FEE �
d�ey artm�en�t.� ��` /f„� WqTERCLOSET �J NEARE TV
Date�L ADDlicant �,u
- / BATH TUB � CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' , � / iy��J
. COMPENSATION INSURANCE . SHOWER OWNEP LC Y/
MAIL p
LAVATORY � Gb qDDRESSI / .,CHL� '�"��
(This section need not be completed 'J the work invoived 0
by,the permit is for one hund�ed dotlars (SI00)or leu.) S�NK
. . /t) CITY llj6/ TEL.NO�/Y/�191P/Jp V
- I certify thet in the performance of the work for which this �ISHWASHER ¢ -
permit is issued,[shall not employ any person in any manner
CONTRACTOR � �
so as to become subje2t to the Workerc'Compensa[ion Laws� CLOTHES WASHER d"'�� AODRESS��3�� ��1�� �� U
Date� Applinnt � � SWIMMING POOL RECEPTOR 0.
NOTICE TO APVLICANT:ft,after making this Cettiflcate of CITY TEL.N0.9G�j/'�O� N
Exemption,�you should�be[otne svbject to the Workers' � LAWN SPHINKLER SYSTEM - ' gTATE UC. y� z
�7 � -
Compensation Drovisions o[the Labor Code,�you muat forth• LICENSE NO. l Z ✓ �� CLASS
with comP�Y-with such D�ovtsions or this permit shall be WATER HEATER �
deemed revoked. � � GAS SYS7EM fOUTLETS � DISTRICT NO. PAOCESSED BY
LICENSED CONTRACTORS DECLARATION / OUTLETS OVER � �
1 here6y af�rm tha[[am licensed undet provisions of Chapter 5 PEH SVSTEM �'� -
9 (commenctng with Section 7000)o[Division 3 of the Busi• F�NA� ALIDATION
ness and Professiona Code,end my iicense is in full force and DATE jU��s—� ,
etfect. - - . . . . .
�7!�� //v� FINAL
Licenee Number��Lic.Cleas v � 8� � z � �
Contractor � � Date�`a �/ � � �
� t am exemyt from the icensing requirements ss 1 am a Plan check fee ;
licensed erchitect or a registered professionel engineer pWMBING PERMIT ISSUING FEE S � ,� . .
- acting in my professionai capacity(Section 7051,Bus•
iness and Protessions Codt). � TOTAL FEE � '
Ltc.�or Reg.No. Date Pian cheek epplicant � � - i
HOME OWNER-BUILDER DECLARATION Name � �
�081,1 A
I hercby affvm that I em exempt from the Confractor's Address e v
License Law for the following reason(Section.103t.5,Busi- Clty � Ts1.No. - �` � �~.�� � -
ness and Professions Code): � ,� a•�6 9,�� I
� 1,as owner of the property,am ezclusively contracting � �
with licensed contractors to construct the project .e • .b 2 5�� . '
(SectWn 7044,Husiness and Nrotessions Code). . . . . _ �
CONSTRUCTION LENDING ACENCY � �`D Q�-r�
I hereby affitm ihat there is a conatruction lending agrncy - �
for the performance of the work for which this permit is , - . - �
issued(Sec.3097,Civ.C.). . , � � � .-
LendePs Name � -
Lender's Address - , .
I certity that I have read this application and state that the - . ,
above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE �� � -
ordinances and State Iaws regulating Plumbing,and hereby . . .
authorize representatives of this County to enter upon the - � � �
,/�ab e-me tioned erty for inspeclion purposes. . � - .
Q.� �i� ��'� � _"�"_� , . . .
ignature of Permittee Date
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