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HomeMy WebLinkAbout0810A WORKERS'COMPENSATIONDECLARATION �swetvw I hereby a�rm �ha� I have a'certificate ot�o�s�t�o5e« <a.,,,=-.o, � APPLICATION FOR�PLUMBING PERMIT - insure,or a certificate of Workers'CompensaHon Insurence,or . . . . , ` �. '. . ��- �certi�ed co ihe�eof(Sec.3 0 Lab.CJ � r@�a-,�'�ir/�/a���'� COUNTYOFLOSANGELES BUILDtNGANDSAFETY • Policy No. Company �� - � � �� � � � �.� a„� ❑ Ce ' copy is hereby furnfahe . F�R APPLICANT TO FILL IN(PRINT OR TVPE) � BUILD�N6 - Certified copy is fited with t county buiiding ins ecC n NUMBER FIXTURE OR ITEM � �E ADDRESS Q�� � � de arfine . � � � � WATER CLOSET . �� � LOCALITY . t Date�-�L Appticant N AREST � . � BATH TUB � �../ CRO55 ST. . CERTIFICATE OF EXEMPT[ON FROM WOR ERS' / , � COMPENSATION INSUftANCE . SHOWER � OWNER ,i�v MAIL / (This�section need not be camplefed if the work imoWed � �AVATORY� - � � d`� qDDRE55 -![--cLs�.awi �+�+c-�J } by the petmit in fa one hundred do�axs (SI00)or leu.) SINK- �` � � � /�–� CITY • �� TEL.NO.oT19.,jy)o U _ I cerlity that in the Derformance of the work for wh�ch this DISHWASHER permit is Issued,1 shell not employ any person in anY menner � CONTRACTOR V�J � �, � so as to betome subject to the Workers'Compensafion Lawe. � CLOTHES WASMER ADDRE53 O �Date -' ADP�icant � . . �`3`3`3� � W � SWIMMING POOL RECEPTOR d NOTICB TQ APPLICANT:If,after meking this CerHflcate of CI7V TEL.NO,���'No/ N � Exemption, you should become'suAject to the Workers' LAWNSPRINKLERSV57EM � gTATE r LIC. /� '/ Z CompensaHon provis3ons of the Labor Code,you must forth• � WATER HEATER � LIGENSE NO. `� ,f p CLASS C` �yb � with comply with such provisions or this perroit shali be �deemed revoked. � � GAS SVSTEM �ISTRICT NO. ROCESSED 8V j OUTLETS � � i LICENSED CONTRACTORS DECLARATION � OUTLETS OVER __ 1 hereby affirm tNat!am iicensed unJer provisions of Chapler / 6 PER SVSTEM / f/`-;� . . , 9(rnmmencing with Section 7000)of Division 3 of the Busi• � � �-� � �� � FINAL ALIDATION � ness and Professions Code,and my license Is in full torce and DATE �(J—�,�'� effect. - � , / _ . � .._ . � License Number�l���Lic.Class � �" 'p FINAL � �- /�,, - �'�e�`�� BY ��C Contracior�[��E�4,�,1�/Dete_� _ � I am exem0�from the l�ensing requitements as I am a Plan check fee � . - licensed architect or a regiatered professional engineer pLUMBING PERMIT ISSUING FEE S ,� � . accinC�n my Droteuional cepacity(Section 7051.Bus• � . iness and ProfessJons Code). . TOTAL FEE � � Lic.or Reg.No. Date Plen check applicant =O 8��O A Neme � . - N. • . .`�,' . HOMF.OWNER•BUILDER DECLARATION � � � '� I hereby affvm that I am exempt from the Contractor's Addreas � �,''��7,J�� License Law for the following reason(Section.7031.5.Busi- City � - � � Tsi.No. � � ��� �a'7�•;v� - ness and Professions Code): � � I,as owner of the properly,am e:clusivety cmtrecting � - � , O�D,O Q-�� � with licenscd contractors to construcl the project _ . � (Sedion 7044,Businss and Profasions Code). . - . CONSTRUCTION LENpING AGENCY ' . . I hereby atCrm that there is a consWction�ending agenoy tor the performance of the work for which this permit is . � . . � issued(Sec.3097,Civ.C.). � � Lender's Name Lender's Addrcss � 1 eertify that I have read this appllcation and state that Ihe � above information is correcl.I ag+ee to compiy with atl County SEE REVERSE FOR EXPLANATORV LANGUAGE � ordinances and State laws regulating Ylumbing, and hereby - . authorize repreeentatives of this County to enter upon the _ above-mentioned pro rty tor inspection purposes. �- � � 7��r•��w �� -d�/ � Signature of Permittee Dete � � c� � � G� p 2 �n .�.� P G -1 N 'f C O �o N 'I� t �L "��,� '� v ' �Z Z — �'p r. ' � N 1 T'm �t 2 r ➢ O , - m�� `, o -', ;, 's' . C, 3 F Y . �� � .. � ;�� � • ,�.O N . .. - . ' . � � vY '� , O. Gya ��. ' � � __ . , i - "f �' ,n N 'mT+�� � , . -� .. ' O � �.� <� �. � ♦ 1� ti � �p r � ,'„m . •-. 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