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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 g G v = � y � 2� � . - � G G� P o 1'N cn � m -p - -n .�1 T'N G .� C �O Z 1� -o 2 % ,i � D rt' � '0 t O �-- zZ ..1 Z 2 f . - ' �� , D(' '.n � � � � � � � 9 . �,v',-� , O � Z . P `r `N ' ' ' t, �D � �� Dm x O , ',a� 1 p � �n � ��' . 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