HomeMy WebLinkAbout1780A (10) WORKERS'COMNENSATIONDECLAAATION ��^���� qPPLICATI4N FOR PLtJMBiNG PERMIT �
I hereby aTfirm that I have a certificate of consent to sclf ce sn(s-eo�
insure,or a tertificate of Workers'Compensation Insurance,or
a certified copy lhereut(Sec.3600,Lab.C J
� COUWTY OF LOS ANGELES BUILD{NG AN�SAFETY
Policy No. Company
I � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING n2d1_�7 /l��r(, SV R(�;tr"r'
AD�RESS .i�1 I�/ C�
� CertiCed capy is filed with the county building inspection NUMBER FtXTURE OR ITEM • FEE t
department LOCALITV �'�,t(]�y'J� e� Fj(,�Q ¢(j�j,��,�J�� 4Y
Date Applicant WATER CLOSET /
NEAREST n�!y p,
BATHTUB CROSSST. UTAr�4f�-Q L7�tY� 1�Vn
CERTIFECATE OF EXEMPitON b'NOM WORKERS' �
COMYENSRTION ENSURANCE SHOWER OWNER �}�' J sIAf6{,Q���
MAIL
(7'his seMion need nos be completed if the wock involved �/+vqTORY qooREss 5�'�" a '
by the permit is fox one hundxed dollazs (5100)or less.) SINK f�q�/ �� Q '
CITV p .A� TEL.NO. ��.0 U i
7 ceriify that in the performance of the work tor which this DISHWASHER � �
pe�mit is issued,[shall nnt employ sny person in any maaner CONTRACTOR Q�{l�� Q I
so a o b ome subject to the '>rke�s' enSation Laws. CLOTHES WA5HER qpDRESS � (~j �
Dat pplicant W �
SWIMMING POOL RECEPTOR �
NOT E O APYLiCANT:tf,af[er mak'r t �s Cert'ec te nf CITY � 7E�.NO. . � E
Exempt' n, you ahould become subjec tt�e okers' LAWNSPRINKLERSYSTEM STATE ILC. Z �
Coinpensation provisiOns oC the Lxbor Code,you must forth- yyqTER HEATER LICENSE NO. CLASS
with comply with such provisians or this permit shall be -s �
deemed revoked. f GAS SYS7EM i OUTLETS �� �ISTRICT NO. PROC SSED BY �
LiClNSED WNTRACTORS DECLARAT[ON OUTLETS OVER �Ca �u,u,��c/ j
1 heroby affirm tha[[am licensed wider provisions of Chapter 5 PE R SvSTEM �
9 (commencing with Sectian 7000)of Divi.sion 3 of the Busi- - FtNA�
� ness and Yrofessions Code,and my ticense is in full force and � •^- d�� DATE �l�,L VALIDATION
effect. �
��License Number Lia C4ass FINAL f/'�, �
BY [�-(u.l�""� 3
�Contractor Date j
l am exempt from the licensmg requirements as[am a Plan cheek fee �
lieenaed architect or a registered yrofessionai engineer pLUM61NG PERMI7ISSUING FEE$ ��} �
acting in mY Drofessional capacity (Section 7051. Bus- -:/ti 9
iness and Professions Code). TOTAL FEE ( y �(j r� ��C A �
'c.or Reg.No.� Dete Plan chack aPP�ican< q �
fj�-�.� � �5 r
HOME OWNER-BUtLDER DECLARATIQN Name �
.. . �--� - --_�-.•�_.�1.4i Q .
hereby nffirm Ohat I am exempt frotn the Contractor's ���e� � -- - -�- � � � �
_.._. ._. . .. _ .._. .._. ._:. .. _.
cense i,aw for the following reason (Section,7031.5, Busi-� GitY Tel.Ntl. � � �°�' ` 3 C.:C�V� �
s and Prafessions Code): i
i,as owner of the propnrty,am exclusively contracting , ���'�y—�� I
with licensed contractors to construct thr project
(Sactiort 7044,Business and Profesxiunx Code).
CONSTR6CT10N LENUING AGENCV
reby aftirm that there is a constructiun lending agency
the performance af tke work for whiclt this permit is
d(Sec.3097,Civ.C.).
er's IJame
er's pddrass
ify that 1 huve read this application end state that the
informati0n is corroct.I agree to coMply witfi all County SEE REVERSE FOR EXPLANATORY LANGUqGE
nces end Stste 18ws rtgulating PlumNing, anfl here6y
rize repreaentatives of thia Caunry to enter upon ihe
mentioned Dro erty f r inspection yurposee. -
�� � � 3 �z
uture of Per itfe Date
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