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HomeMy WebLinkAbout1350A (7) 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` �� ' nature mittee Date � - I � I � � � . � � _ °;. `\ � � C o �+ ay�;~ � ,, . . ,. � t� c ,-''� ^ °' \ . , a,•� 9 a c.� °' o � � '' � °' j � � �� ~ � � ; , o � � Y o ` �d L x' y�' �°' C l�-� � a O O C. . ,n,;,':� _°' Q,O v o °1 L '' y ..n c��-= a� ' 1 , , ��m�� 3'w� �M � O y� 'd0O V„�.��y � , , . �. » Y � C�y.., �. 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