HomeMy WebLinkAbout1828A (11) WORKERS'COMYENSATION DECLARAT[ON oswas�w �
1 hereby af£irm that I have a certificate or�ons�t t�self �E.,�,=-.a, APPLICATION r�OR PLUMBIfVG PERMIT
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.CJ/ COUNTY OF LOS ANGE LES BUI LDIN6 AND SAFETY-
Policy Nd •��/S��fCompany G�-4�r.>1-Qci.,.Gvi[.� , .
�' � Certifled copy is hereby furnished. FOii APPLICANT TO FILL IN(PRINT OR TYPE) BUII.DING l/��`s� �/ /
ADDRESS /' 7 Q�
� Certified copy is filed with the COUnty bUilding inspeCtion NUMBER FIXTURE OR ITEM • FEE
Date� Partment. App���ant� ���% - (J./"' /OG�_ W�4TER CLOSET d V NEAREST �Y ��
BATH TUB CROSS ST. V H 1
CERTIFICATE OF EXEMPT[aN FROM WORKERS'
COMYENSATIONfNSURANCE SHOWER �Q OwrvER � �
LAVATORV MAIL � �
(Tliis section need not be completed if the wock invotved �� qo�ftEss 3�ly 5 f 4'� ;...c
by tl�e permit is foc one huudred dciltara ($100)or Iess.) }
SINK CITY �rt��� TEL.NO. O
I certify that in the performance of the work for which this DISHWASHER U
permit is issued,L shal!not emptoy any person in any manner CONTRAC70R -r' Q �
so as to become subject to the Wor&ers'Compensatiun Laws. CLOTMES waSHEFt �
AD�RESS O
Date Appiicant � � F-
SWIMMING POOL RECEPTOR
NOTICE TO APYL,ICaNT: If,after making this Certificate ot CITV .K` TEL.N0.6(,f�/f�+� � '�,
Exertiption, yoU 5hould hecome Subject to the Workers' LAWNSPRfNKLERSVSTEM STATE �I LIC. t�l7 ''
Compensation pro��ir,ions of the Labor Code,you must forth- UCENSE NO. !t G i ���. CLASS -)� � '�
with cnmply with such provisions or this permit ahxll be WATER HEATER ) _
deemed revoked. DISTR�CT NO. PROCE$SE� �
GAS SYSTEM OUTLETS �7 1
LICENSGll CONTRACTbRS DECLARATiQN OUTLETS OVER f!f y '
I hereby affirm that[am licensed under provisions of Chapter 5 PER SYSTEM !
9 (commencing with Section 7000)of Division 3 of the 8usi- ��NA� j� VALIDAT�ON �
ness and Professions Cnde,and my license is in full force and �ATE q g3
effect. i
License Number� � a' Lic.Class C—?� FINA � �
BY �Contractur�ec_= /0� Date ?f,¢.�iT2
� I am exempt from the Iicenaing reyuirements as 1 am a Plan cfieck fee �
licrnsed architeM or a tegistered professionat engineer 1
acting in my prufessionn}eapacity(SeMiun 7051,Hus- P�UMBING PERMIT ISSUING FEE$ ��
iness artd Rofessions Code). TOTAI FEE �
Lic.or Reg.No. Date Plan check applicant �1 8 2 8 A j
!
HOMb OWNER-BUILUER UECLARATION Neme #• • • • •5
Address �
I hnre6y nffirm that [ xm exempt fzom the Contrac[or's E • •L Q. 'Jr 0
License Law fur the fallowing reason (Section 7031.5,Busi- Ci2y Tel.No.
ness and Professions Code): 7� • •2 Q�j Q� i
� [,as owner of the proyerty,am exc�usive�y contractinq 0�� Z=S� �
with licens¢d contractars to cons[ruct the projeci
(Section 7044,Business and Professions Code). �
CONSTRUCSION LENDINC AGENCY i
I hereby affirm that there is a construction lending ugency �
Cur the performance of 1he work for which this permi[ is
issued(Sec.3097,Civ.CJ. i
Lender's Name �
i
Lender's Address i
�
I certify that I have read thie application and state that the i
above information is correct.I agree to comply with all County SEB REV ERSE FOR EXPLANATORY LANGllAGE �
ordlnances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter uDon the
above-mentiorted property for inspection purposes. � '
--��`/�� � ?7���? I
Signature of Permittee Date �
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