HomeMy WebLinkAbout1210A (6) WORKERS'COMPEMSATION DECLARATION �swsa�w �
I hereby affirm �he� , he�r a certificate o��o���to self �Ee,,,=-�o� APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workere'Compensation Insurance,or
a certified copy thereof(Sec.3800,L b.C , COUNTY OF LdS ANGE LES BUI LDIIVG AND SAFETY
Policy NFl��mpany , `�
I � Certitied copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) qDDRESS mC. ' I
F 7d Certified copy is filed with e cou t �Id� g ins rt NUMBER FIXTURE OR YfEM • fEE �
��`�� ar e WA7ER CLOSET LaCAIITY �
Date�Applican NEAREST
BATH TU6 CROSS ST.
CERTFFFCATE OF EX£MPTION FROM WOk ti S'
COMPENSATIONiNSURANCE SHOWER OWNER
MA1 L
(This section need not be completed if the work involveal �AVATORY qpDRESS a
by the permit is for one hundred dollaca (5100}or less.) SfNK �
CITV TEL.NO. U
I certity that in the pertormance of the wurk for which this DISHWASHER CONTRACTOR �
permit is Issued,I shal[not employ any person irt any manner Q
so as to become subject to the Woekers'Compensation Lews. CLOTHES WASHER qD�RESS U
Date Applicant �� W
SWIMMING POOL HECEPTOR
NOTICE TO APPL[CANT:lf,after making this Certificate of CITV �n 7EL.NO �
Exemption, you should 6ecnme subject to the Workers' LAWN SPRINK�EA SVSTEM STAT 41C. �
Compensation provisions af the Labor Code,ynu must furth- WATER HEATER LICENSE NO. CLaSS�. �
with comply with sueh provisions or this permit ahall be �
deemed revoked. DISTRICT NO. PflOCE55ED
GAS 5VSTEM OUTLETS �
L[CENSED CONTRACTORS DECLARATION OUTLETS OVER __�_ � i
I hereby afPirm that I am licensed under provistons of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code,and my liceese is in fWl force and DATE
effect.
^�� C��� FINAL
Lirense Number� c.�� Lic.Class gy
Contractor�cDf?a� Date L—1��U�
:_� � � �. ,., �
� f am exempt Crom the Iicensing requirements as I am e Plan check fee _ � _ � �
licensed xrehitect or a registered prafessional engineer pLUMBING PERMIT ISSUWG FEE$ � M ` i
acting in my proYessional capacity (Section 7051, Bus- a �
Ine55 and Prufessions Code). TOTAL FEE Q � w e j � ,` ('� g
Lic.or Reg.No. Date Plan chaek applicant " ` '* �- ' 3C
Name ' /;^.� ' �
HOME OWNER-BUtLDER�ECLARAT[ON ' .. :. i . i
I hereby affirm that I am exempt from the ConFractor's Address
License Law for the foliowing reason (Section��3t.5,Busi- City Tel.Na. � �
ness and Yrofessions Code): � �
i
� i,as owner of ihe property,am exclusively contracting �
with licensed con[ractors to cortstruct the project
(Section 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY j
i hereby affirm thet there is a construc[ion lending agency !
for the performance of the work fur which this permit is �
issued(Sea 3099,Civ.C.). �
Lender's Name
Lender's Address
9
I certify that 1 have read this application and state that the �
abuve information is mrrect.I agree to comply witb all County SEE REVtiRSE FOR EXPLANATORY LANGUAGE
ordinances and State laws reguluting Plum6ing, and hereby
autho ize representatives of[his ounty to enter upon the �
abov� mentioned pr t�for i ction purposes.
�
nature of Perm�ttee Dat �
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