HomeMy WebLinkAbout1218A (6) WORKERS'COMPENSATION DECLARATION �awae+a �
I hereby ajfirm tha� � have a certificate ofconsent to self �E..z,z-.o, APPLICATiON FOR PLUMBING. PERMIT �,}
insure,or e certifica[e of Workers'Compensation Insurance,or �� :
a certified copy thereof(Sec.3600,Lab.C.) ;
.L�vf �� UA1r—(�F}/�� COUNTY OF lOS ANGELES BUILDfNG AND SAFETY
Polity N Company
I � Certifed copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT QR TYPE) BUIL�ING �
�-,�,/ ADDRESS I
�,�(� Certified copy is filed with t county i �ng i tion NUMBER FIXTURE OR ITEM • FEE
"� ar e LOCALITY ,.1 f
Date �r Apptican WATER CLOSET NEAREST w D
BATH TU8 CROSS ST. �
C@RTIFiCAT6 0F EXEMPTION FROM WO K RS'
COMPENSATIONINSURANCE SHOWER OWNER
(This sect/0� tIPRd not be completed if the wOtk IllvOlvfd LAVATORY ADDRESS d �
by the permit is fw one l�uadmd dotlazs (5100)oi leag.) SiNK CITY TEL.NO. U
i certity that in the performance of the work fur which this DISHWASI-kER CONTRACTOR a �
permlt is issued,I shall not empioy any person in any manne[
so as to bacome subject to the Workers'Compensa[ion Laws. CLOTHES WASHER � ` U
AD�RESS y
Date Appiicant SWIMMING POOL RECEv70R / � � W �
NOTiCE TO APPLICAMT:If,after making this CertiFcate of �� CITY � �, TEL.NO, r� y �
Exemption, you ahould become subject to the Workera' LAWN SPRINK�ER SY5TEM Z
Compensation provisions of the Labor Code,you must torth- STA7E LIC. — �
with comply with such provisions or this permit shell be 1M1�ATEfi HEA7ER LICENSE NO.� �J CIASS �`� �
deemed revoked. GaS SVSTEM OUTLETS �ISTRICT NO. PROf ESSED 8Y �
LtCENSED WN7HACTORS DECLARATION OUTLE75 OVER ! � �
1 hereby uff'vm that[am tticensed under provisions of Chepter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL �
ness and PrnPessions Code,and my license is in full force and �ATE VALIDATION
efPect.
LicenseNumber6�.� Lic.Class L���/ F�NAL �
Contractor�Tn� D� Da[e �—���(� �
� I am exempt from the licensing reyuirements as I am a Pfan check fee �
licensed architect or a registered professionai engineer • $
acfing in my professional capacity (Se�Yion 7057, Bus- PLUM8ING PERMIT ISSUING FEE$ ,�0 �
iness and!'rofessions Code). TOTAL FEE �� � �
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BU[LDER DECLARpTION Name -. � `'�'� :; _ �
I hereby aff'vm th•at t am exempt from the Contractor's Address - R s a n o 4
License Law f�r the following reason (Section 7031.5, 8uxi- City Tel.No.
ness an1 Professions Code): � �� T ,.��
� I,as owner of the property,art exclusively conttacting
with licensed contractors to construct the proyect ,• =: s j ;��' ,
(Sectiun 7044,Business and Professions Code).
��.� 4—��
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is x construction lending agency
for the perPormance of the work [or which this permit is
issued(Sec.3047,Civ.C.). �
Lender's Name �
Lender's Address
I certify that I huve read this application and state that the
above information is correct.I agree[o cortply with all County SEE REVERSE FOR EXPLANATORY LANG[7AGE
mdinances and State laws regulating Yiumbing, and hereby
aut rize representatives this County to enter upon the �
ubo�-mentio e erty inspection purposes. �
Signature of Permitt� at6 e � �
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