HomeMy WebLinkAbout1214A WORKERS'COMPENSATIONDECLARAT[ON �•a.•�a � APPLICATION FOR PLUMBING PERMIT
I hereby affirm that 1 have a�certificate of consent to self ce e���x-aa) �
insure,or a certiticate of Workers'Compensation Insurance,or � .
a certified copy thereof(Sec.3800,Lah.C.)
/� ��i COUNTY OF LOS ANGELES BUILDtNG AND SAFETY
Policy . �f f�ompanY'?L�,��(L�
I � Certif'ied copy is hereby furnished. FOR APPLICANT TO FILL IN IPRINT OR 7YPE) � BUtLO1NG ��
ADORESS
�Certified copy is filed with t coun Iding in" tion NUMBER FIXTURE OR ITEM � FEE
p � � WATER CLOSET LOCALITY ��� �
Date Applicant NEqREST
BATH TUB CROSSSL �
CEHT[FICAiE OF EXEMPT[ON FROM WOR RS'
COMPENSATIONINSURANCE SHOWER OWNER '
LAVATORV MAIL '�
(This sec4on need not 6e compteted if the work involved AODREss a i
by the permit is for one hundred doilazs ($100)or less.) SINK �irv TEL.NO. O
I certify that in the perfurmance of the wurk for which this j
OISHWASHER - � �
permit is iasued,[shaR nat employ any person in any mannef CONTRACTOR
so as to become subject to[he Workers'Compensxtion Lawa. CLOTHES WASHER
AODRESS D' +��
�ate Applicant SWIMMING POOL RECEP70R W
NOTICE TO APYLICnNT:If,efter making this Certificate ot CITV � TEL.NO � 3-��? N i
Exemption, you should become su6ject to ihe Workers' LAWN SPRiNKLER SYSTEM '
Compenaation provisions of the Labor Code,you must forth- S7A7E /� LIC. � �
wiih eomply with such provisiona or this permit shall be WATER HEATER LICENSE NO._,L��/�( CLA55 _� �
deemed revoked. GAS SYSTEM OU7LET5 DISTRICT NO. PROCESSED BV �
LICENSED CONTRACTORS DECLARAT[ON � /��
OUTLETS OVER l�
I hereby affirm that I am ticensed under provisions of ChaR�er 5 Pe R SYSTEM
9 (commencing with Section 7000)of Division 3 nf the Busi- RNAL �
ness and Professions Code,and my license is in full force and DATE VALIDATION
eCfecL (
�.�L7 FINAL �
L'etense Number�Yl?S� Lic.Class B� �
Contractort��[� Date I—t( �/
(
� t am exempt from the licensing reyu'uements as[sm a P4an check fee
licensed architect or a registered professional engineer �
acting in my protessional capacity (Section 7051, Bus- PLUMBING PERMfT ISSUfNG FEE$
iness and Professions Code). 1 G
TOTAL FEE Q�
Lie.or Reg.No. �ate Plan check applicant
HOME OWNER-BUILDER DEC.LARATiON Name �
_� L";.i'.j,`
I here6y aff'vm that I am exempt from the Contractor's Addreas "
� r.
License Law for the foliowing reason (Section 7031.5,Husi- C�ty Tal.No. ;� ` " s , �
ness and Professinns Code): y�
� I,as owner of the property,am exclusively contracting �
with ticensed contractors to construct the project � a •:� ,:��/`
(Section'/044,Business and Professions Code). ; �' �
P 2. ; � _
CONSTRUCTiON LENDING AGENCY ' ��L( i �
I h e c e b y a f f i r m t h a l t h e r e i s e c o n a t r u c t i o n le n d i ng agency , . � �
for the performance of the work for which thia permit is
issued(Sec.3097,Civ.CJ.
Lender's Name 4
Lender's Address �
[certify that I have read this application and state that the
above information is correct.I agree to comply with all County SEF.REVERSE:FOR EXPLANpTORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby �
authorize representatives of this County to enter upon the
abo -mentiun rv ert f inspecNon purposes. �� �
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Signature of ermittqe Date ;
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