HomeMy WebLinkAbout1350A WORKERS'COMPENSATIONDECLARAT[ON �•-••�A APPLICATION FOR PLUMBiNG PERMIT
[ hefeby af��'m that I have a ttrtificate of consent to self ce uv(s-co� /7
insure,or a certificate of Workers'Compensation lnsurance,or �l I
a certified copy thereof(Sec.3800,Lab.C.) �,}
y� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N��fpCOmpan � i
� CertifieG cop}r�s h��furnished. FOR APPLICANT TO FI�L IN(PRINT OR TYPE) BUILDING �
mNUMBER FIXTVRE OR ITEM • FEE '4DDRESS � • } �� �
Certified copy is filed with the county 6uilding inSPection
de� en �r 4� LOCALt7Y
llate Applicant d WATER CL0.SE7 �
NEAREST
BATHTUB CROSSST. Z,�....�C.se_�,c�f�1F»;�
CER7IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION[NSURANCE SHOWER OWNER /'
(This section need not be completed if the wock involved LAVATORY qDDRESS , A �
by the permit is for one hundied doltazs (5100) or less.)
S4NK CITY �' � TEL.N0.3 � �
1 certify that in the pertormance of the work for which lhis DISHWASHER , �
perp�it is isaued,I aha�l not empiuy any person in uny martner CONTRACTOR O
so as to become subject to the Workers'Cumpensation Laws. CIOTMES WASHER ADDiiESS /�/� ~
Date Applicaat J�, IC1J V
SWIMMI{JG POOL RECEPTOR W
NOTICE 70 APPLICANT:It,after making this CerEificate uf CfTV TEI.NO. � �f �
Ezemption, you should become subjeci to the Wnrkers' LAwN SPRIFJKLER SYS7EM STATE
Cumpensation provisions of Ehe Labor Code,you must forth- LIC. �
with comply with such prarisions or this permit shall be WATER HEATER LtCENSE NO. C�qgg)
deemed revoked. DISTRICT NO. �VjpOCESSED BV
CaAS5VSTEM OUTLETS /} �
LICENSEDCONTRACiORSDECLARATION QUTLETSOVER ��% v 'j�?��,/
I hereby aff'vm that I am licensed under provisions ot Chapter 6 P R SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi� FINAL ��
i ness and Professinns Code,and my license is in fu(1 foece and -'U� � �ATE �' � �� V/4LIDATtON
+ effect. ,�y�.��
t �
�p�'��,,� 2 FINAL �"��� � V<<�ti-/L✓
License NumberG,L��1_ Lic.Class �—v� BY �F `���
Contractor�,�_ Date �`Z��O��
� t am exempt from the Ifcensirtg requiremenis as I am a Plan check fee I
licertsed architect or a re�stered professional engineer pLUMBING PERMIT fSSUfNG FEE$
acting in my professianal capacity (Section 705 t. 8us- �
inesa and Professions Codn). //7
TOTAL PEE ���
Lic.ur Rng.No. Date Plan ehsek appficant �
HOME OWNER•BUILDER DECLARAT[ON H8f^° I
I hereby atFum that I am exempt from the Contractor's Address L' ` I
�.vH,
License Law for the following reason (Section 7031.5, Busi- Ciiy Tal.No.
ness nnd Protessions Code): }�• .. • • • � �
�� I,as owner of the property,am exclusively contracting �
with licensed contractars to construct the project � ` � � 2 5 U
(Section 7044,Business and Professions Code). • • e � G Jr� �
CONSTRUCTiON LEND[NG AGENCY �
I hereby af�rm that there is a construction lending agenCy � �,�7''�:[
for the performance of the work for which this permit is �
issued(Sec.3097,Civ.CJ. i
Lender's Name
i
ender's Address
cer[ify that [have read this application and state that the �
bove intormation is correct.I agree to comply wi[h all County SEE REVERSE FOR EXPLANATORY LANGUAGE ( -
rdinances and State laws regulating Plumbing, and here6y
uthoriae�sentatives of this County to e=ter upon the � .
bove-m tio d properf inapection purposes. �
1`
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