HomeMy WebLinkAbout1215A WORKERS'COMPENSATION DECLARATION iswsuw �
[ hereby affirm that I have a certificate of�o��t to self �E.,��=_so, APPLICATION FOR PLUMBING PERMIT
insute,or a certi(cate of Workers'Compensation Insurance,or
a certified copy thereot(Sea 3800,Lab.C.)
Policyxo4��LLdCompany-�N� —GA"QE COUNTYOFLOSANGELES BUILDlNGANDSAFETY
' � Certified copy is hereby furnished. FOFi APPLICANT TO FlLL IN(PRINT OR TYPE) BUIL�ING ,
AD�RESS �'
�( CerNfied copy is filed with he county 6uilding insp,ction NUM6ER FIXTURE OR ITEM O FEE — '
•`.•'� pa t e IOCALITY � r— 1
Date Applicant � �NATEfl C�OSET
NEAREST !
BATH TU8 CROSS ST. �
CERT[FICATE OF EXEMPT[ON F'ROM WOR RS'
COMPENSATION INSURANCE SFFOWER OWNER
LAVATORY MAIL
(Tliis section need not be completed if the work involved AooRess
by the pe�mit is for one hundted doAazs ($100)or less.) S�NK G7Y TE�.No. a
I certify that in the performance of the work for which this V
permit is issued,[shalt not emptoy any persan in any manner DISHWASHER CONTHACTOFi ��
so as to become subject to the Workera'Compensation Laws. � �
CLOTHES WASHER qDURESS Q
Date qpplicant / F.
SWIMMING POOI.RECEPTOR � � ��J V
NOTICE TO APYL[CANT:If,after making this Certificate ot CITY TEL.N . <
Exemption, you shou(d Decome subjCct to the Workers' �AWN SPRINKLER SYSTEM 7�� a
��l/ STATE r N
Campensatlon ptovisions n€the Labor Code,you muat Forth- yyATER HEATER LICENSE NO.� �j� CLA55 �'�O�� Z
with comply with such provisions or this permit shall 6e
deemed revoked. �ISTRIC7 NO. PROCES ED BY
GASSYSTEM OUTLETS � � f
LSCENSED CONTRACTQRS DECLARATION OUT�ETS OVER �' � �
I hereby aff'vm that I am licensed under pruvisions of Chnpter 5 PER SVSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL
ness and Professions Code,and rty license is in full force and DATE VALIDATION
effect. �
License Number�/�V7 Lic.Clnss- ` /�� FINAL �
ev 3
/ r ;
Contractor � Date �Il —�
� I am exempt from the licenaing requirements as I am a P1an check fee �
ticensed architect or a registered professional engineer pLUMBING PERMIT ISSUING FEE$ �
acting in my professionnf capacity (Section 705t, Bus- ¢
incss and Professions Code). �� �� �
TOTAL FEE �
Lic.or Reg.Nn. Date Ptan check applicant ' � �- ; �-Y
HOME OWNER-BUILDER�ECLARATION Name ;i a s's � e�
' !
Address !
1 hereby aff'vm that I am exempt from the Contractor's •i � �, R L:'r a
License Law for the following reason (Section 7031.5,Husi- ��ty Tel.Mo. �
ness and Prnfessions Code): � � , ��;� .
� I,as owner oE the property,am exclusively contracting
with licensed contractors lo construct the project ��i � � ���
(Section 7044,Business xnd Profwsions Code).
CONSTRUCTtON LENDWG AGENCY
I hereby affirm thaf there ia a cons[ruc[ian lending agency
for the performance of the work for which this permi[ is
issued(Sec.3097,Civ.CJ.
Lender's Name
Lender's Add[ess
1 certify that [have read this application and state that the
abnve information is correct.I agree to romply with a11 County SEE REYERSE FOR EXPLANATORY LANGUAGE
urdinances and State laws regula[ing P(umbing, and hereby
authu ize representxtives of t iis County to enter upon the
abov entioned roperty spection purpuses.
Signature of 3 rmittee Uate �
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