HomeMy WebLinkAbout1216A YORKERS'COMPENSATIONDECLARATI�N ��was�i � APPLICATiON FOR PLUMBING PERMIT I
1 hereb aFfirm thut I have a certificate of cons t to self cE e�� z-eo �
insure,or a certificate of Workera'Compensation Insurance,or ,
a certified copy thereof(Sec.3800,Lab.CJ COUNTY OF LOS ANGELES BUILDING AND SAFETY '
PolicyNa�'���lU3Companyll��/ ^����
� � CedifieS copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING,
AOORESS 3
�Certified cnpy is filed with e county b 'i ' g insp n NLIMBER FIXTURE OR ITEM • FEE
ar e WATER CLOSET LOCA�I7V A f
f1
Date Applicant NEqREST �
BATH TUB CROSS ST. �
CERT[FICATE OF EXEMPT[ON FROM WOR S'
COMPENSATIONiNSURANCE SHOWER OWNER
LAVATORY MAfL }
(Tliis section need not be completed if the work involved ADDflE55 a I
by the permit is for one hundred dollacs (§100) or less) p
StNK CITY TEL.NO. Ca !
I certify that in the performance of the wotk for which this OISHWASHER (t �
permii is issued,i shatt not employ any person in any manner CONTRACTOR . Q
so as[o become subject to the Workers'Compnnsa[ion�Laws. CLOTHES WASHER U �
Date A licant ADDRESS O � � .
PP � SWIMMING POOL RECEPTOR W �
NOT[CE TO APPLtCwNT: It,afier making this Certifcate uf CITY �� ? TEL.NO �-� y �
Exemption, you should become su6}ect Eo the Wo�kers� lAWNSPRINKLEHSYSTEM ^� � Z �
Compensation provisions of the Lahw Code,you mu:t forth- LIC NSE NO.(][�� f., CLASS �'A�o
with comply with such provis'rons or this permit ahall be WATER HEATER
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PROCES BY F
LICENSED COniTRACTOHS DECLARATION � f� U �
OUTLETSOVER
I hereby atfirm that L am lirensed under provisions of Chxpter 5 PEH SYSTEM �
9 (commencing with Section 7Q00)of Division 3 oP the Busi� FINAL �
ness and Professions Code,and my license is in full force and DATE VALIDATION
effect. �
FINAL
License Number Lic.Class C�a� gy ,'-.j %1 F,� '
Cuntractor,�.�Q�L� Da[e ��l( �O / ,"a e • a .. G 1
� i am exempt from the licensing requiremertts as F am a Ptan eheck fee �
ficensed arehite�K or a tegistered profesxional engineer � ��`� n r r
ac4ing in my professional capacity (Section 7051, Bus- PLUMBING PEHMIT ISSUING FEE$ � ` _
iness and Professions Code). TOTAL FEE �
`'r. ; f. —`.' 1
i
Lic.or Reg.Na. Date Plan check applicent � � �
I
HOME OWNER-BU[LDER DECLARATION Name �
1 hereby aff'vm that I am exempt from the Cantractur's �dress
License Law for the following rea.son (Section 1031.5,Busi- CitY Tel.Nn. }
ness and Protessinns Code): ;
� [,as owner of the property,am exclusively contracting � �
wiih licensed contractors to construct the project
(Sec[ion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY �
I hereby affirm that there is a construction lending agency !
for the performance of the work for which this permit is �
iacued(Sec.3D97,Civ.C.). �
Lender's Name
i
Lender's Address �
1
I certify that I have read this aDP4ication and state that the �
above intormation is coreect.I agree to comply with all County SEE REVHRSE FOR EXPLANATORY LANGUAGE �
ordinances and State laws regulating Ylumbing, and hereby
author'e representatives of this Counry to enter upon the -
above entioned pe ty fo i pection purposes — �
Signature of Yermittee Date �
I
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