HomeMy WebLinkAbout1211A (6) WORKERS'COMPENSAT[ONDk:CLARAT[ON ,�•.��A APPLICATION FOR PLUMBING PERMIT �
I hereby aPPtrm that I have a'certificate of consent to self ce n��z-so)
inauce,or a certircate of Workers'Compensation Insurance,or
a certified copy themof(Sec.3800,Lab.C.) COUNTY OF LOS ANGE LES BUI LDt11lG AND SAFETY
PolicY N � Q �"CompanY�41V��1 iz=
� � Certitied copy is hereby furnished. FOfl APPLICANT TO FI LL IN(PRINT OR TYPE1 BW LDING • j�
ADDRESS �J '�
� Certified copy is filed with t e count � �ng in e ion NUMBEFl FIXTURE OR ITEM • FEE � f �
Date�e WATEF CLOSET �OCA�ITY �`,
Applicant NEARESF
BATH TUB CROSS ST.
CERTIF[CATE OF EXEMPTiON FROM WOR E S'
COMNENSATIONIN5URANCE SHOWER OWNER
LAVATORY M'41L �
(This section rteed not be completec! if t}�e work involved AD�RESS
by ihe permit is for one hundred dollazs (St00)or less.) SINK d
CITY TEL.NO.
1 certify that in the performance of the work for which this DISHWASHER /, � � �
permit is issued,I shall not employ any person in any manner CON7RAC7oR
so as ta hecome subject to the Workers'Compensation Laws. CLOTHES WASHER A�ORESS ✓1/��/ _ � Q
Date Appiicent 4 /a H �
SWIMMING POOL AECEPTOR �
NOTICE TO APPL[CANT: If,af'ter making this L'ertificate of CITY ��� TEL.N W �
Exemption, you should become suAject tn [he Workers' LAWN SPRINKtEfl SYSTEM STATE ���, y
Compensateon provisionx uf the Labor Code,you mvst Por[h- yrpTER HEATER UCENSE NO.� � CIASS �� � � �
with comply with such provisions ar this permit shall 6e �
deemed revoked. GAS SYSTEM OUTLETS D4STRICT NO. PROCESS 8Y
LICENSEDCONTRACTURSDEC6ARAT1pN � 4
Ot17LETS OVER � y
I hereby a[firm that 1 am licensed under provisions of Chaprer 5 PER SVSTEM . 4�
9 (commencing with Section 7000)of Division 3 of thr Busi- PINAL �
ness and Protessiuns Code,and my ticense i.c in fuli force and OqTE VALIDATION
effect.
License A{umber� `17�"' Lic.Ctass �`�� FINA� �
t �`l���� BV d
Contractor���.� Date
&
� t am exempt from the licenaing reyuirements as[am a Plan check fee j
lYCenSed a[Ch[teCt Ui a registered professional engineer pLUMBING PERMIT ISSVING FEE$ d
acting in my professional capaeity (See[iun 705t, Bus- � � �
iness and F4ofessions Code). TOTAL FEE �
Lic.or Reg.No. Date Plan check applicant - '� r:] � �,
HOME 01VNER-BUILUER UECLAKATION Name ,�r � m � � a c,
I hereby affirm [hnt I am exempt from the Contractor's Aedress 1 � � f ,:t'�
License Law for tNe fullowing reason (Section 7031.5, Busi- CitV Tel.No. _ �
ness and Professions Cnde): s ; .. � ,.
� F,as owner of the property,am exclusively contracting
with licensed con[ractors to construct the project �=' ; (;.--�':� �
(Section 7044,Business and Professions Code). .
CONS7RIICTION LENDING AGENCY �
1 hereby affirm that there is a construction lendine agency
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name
i
Lender's Address f
I certify that I have read this application and state that the t
a6ove information is correct.I agree to comply with all County �
ordinances and State laws regWating Flumbing, and hereby SEE KEVERSE FOR EXPLANqTORY LANGUAGE
�utho ize representatives of thi ounty to enter upon the �
abov entiung p � for i p ction purposes./ ��
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Signature of Permittee Da e �
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