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 � �
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