HomeMy WebLinkAbout1288A � •.
WORKERS'COMFEI3SAT10ND£CLARAi70N 96w6f>Y APPLICATION FOR PLUMBING PERMIT r,� �
[ hereby aPfirm that I have a certificete af consent [o seif ce eu(s-■ol
insure,or a certificate ot Workers'Compensation Insurance,or � �
a certifiad copy thereof(Sec.38p0,Lab.C.)
COUNTY QF LOS ANGELES 9W LOtNG AND SAEE7Y ___
Policy No. Compan � �
I � Certitied copy is hereby furrtished. FOR AVPIICANT TO FILL IN(PRINT OR TYPE) � ��-- �VILD�NG p
• NlJMBEF FIXTURE OR iTEM • FEE . A�ORESS_ ���-J � -
� Certified copy is filed with tl unty bylldtny inspection � �'j -�����
depit t. 6 � IOCAlfTY . .��a '. . .�.
- WA7ER CLOSET
Date Applicyni �EAREST _ / _
- � � BATH TUB CROSS 57. -GC,/Cm��l �
CERTIFSCATE OF BX�MPT10 PROM WORKERS' . ��� �'��-���� "- �� �-����- �� ��� ��
. ........... .... . .._.
. ... . �....
COMPENSATION[NSURANCE sffaWEp OWNER .
LAVATQRY MA�L .�....-- '-...._....._ . . ... . . y
(This section need no[ be wmpleted if tEte work involved � ADDRESS " �-
by the pe:mit is for one hundred dollars (5100)ai less.) S1NK ��TY _ - 're�.NO f/S"la U ,
f certify that in the perfoimancC of the work for which this OISHWASHEH � I
WNTRACTOR .
permit is iasund,I shall not employ any person in any manner . � 0 i
w as to bscome subject to the Wwkorn'CompensaHon Eaws. CLOTHE5 WASNER _ . � --- �-��-'�� -�"-- ��""��" � v i
co AD�RESff-----------
Uate Applicant SWIMMING POOE HECEPTOfl d �
NOTICE TO APY4ICANi:If,afier maktng fhis Certifica[e of CtTY '� TEL NO. • � i
� tixemplion, you should become subjact to the Workers' LAWN5PRfNKLERSYSTEM S7A7E � - LIC. — J
Compensation provisions of the Labar Code,you muat forth- � � LICENSE NO. ��� CLA55 �"�� !
with comply with such provisions or this pncrtit shali be WATER HEATER � _
deemed revoked. G9.5 SYSTEM OUTLETS � O15TRICT NO. PFLO ESS6D 8Y �
� ___. _ __ __ i
LICENSED CONTRAL'TURS DECLAAATION- - � -- - - '" �-----�--— ��� • 4�-<-r-tr-
DtJTlETS OVER--— i
�� 5 PER SVSTEM - 1
S hereby afficm thni l eai licensed�oder groviniauof Chaptet - ---- --------"---�-- `
9 commencin with Srttion 90001 of Division 3 af the Busi- - - - FINA � �
' ness and Vrotessions Code,aIId mY licence isin Fulk iMce uid OATE - _ ..�tj �'�.. .vALI�AZ�ON. _ .. �
i
e€fect. /� / j
i License Numb � �" Lic.Class �~�• _ ....... .. . . . BY A ;
) �
`Con[raciar Date J/+ �
� I am exempt rom tAe licensing ttUui[emertts as!am a Plan check fee �
licensed architeM or a.regis[ered prufesseonal..�n�inecr pLUMBING PEHFAIT 4SSUING FEE$ �
acting iw mY P�pfz��at-:capasi3Y (��+�zOSt, B�� '
iness xnd!'rofessions Code). TOTAL FBE � �
�1288A
Lic.ur Rng.No. � Date_ P�an check epplicant
#. . . . .5.
HOME OWN�R-BtJ[LDEft aEELARATtOM Name
. __ ._ - � ---.._ ---�-—_. . - � • •j 2..�.6
_
I hereby affirm that I am ezempt fcom the ContractoPs Address "- � � .
License L•.w tor the fullowing reason (Seotion 9031.5,Busi- p�tv Tel.No. • • �1 2 5 G� .
ness and Profassions Code): _
� [,as uwnec of the pcaperty,am ¢zclUbiv¢ly contracting . C�,� g'�G G
with licensed tontractors to construct the project , - �
(Sedion 7044,Husiness and Professions Code). . - � ' ' '.
� .. •
! CONSTRUCTIUN LENDING AGENCY � � I
h I hereby afPirm thet thece is a construction lending agency
for the performance of the work for which thia permit is
�issued(Sec.309�.Civ.C.). i
Len4er's Name '
�
�Lender's Address !
I certify that 1 have resd this appiication and state that ihe
�above information is correct.]agree to comply with all County ', SEE REVERSE FUR EXPLANA'IORY[,ANGUAUE
ordiiianres and Stnte laws regulating Plumbing, and hereby
�authorize representatives of this County to entec upon the '
;above- en' ned pro erty(or inspection urpo s. �
/ / �.Z �
Signatur ermi:.cc Date
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