HomeMy WebLinkAbout1829A WORKERS'COMPENSATION DECLARATION vuaarw � I
I hereby affirm that I have a certificate otconsept to self �E.,�,Z-.o, APPLICATION FOR PLUMBING PERMIT �
insure,or a certificate o(Warkers'Compensatiun Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
y 69!'3U5'H��,�y�p�Cw{L/,a..zv�`c� COUNTY UF LOS ANGELES BUILDING AND SAFETY i
Polic No
� • � Certified copy is hereby furnished. FOR APPUCANT TO FILL IN(PRIN7 OR TYPE) BUILOING �
ADDRESS �+3�y
❑ �ertified copy is filed with the county buiiding inspection NUMBER PtXTURE OR ITEM • FEE
d artment. LOCALITY _
_�� 2 �I.(�f�,��,.� �� WATER CLOSET ,. �� h
Date App6cant NEARESS
BATHTUB e� CROSSST.
CERTIF[CATE OE'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCti SHOWER Q(} OWNER
LAV ATORY MA�L �o �
("Fhis section need nat be comQleted if the woik involved � ,4pppEss L{�( ' j"c( -u,.�.
by the permit is for one hundred dollus ($!00)or lessJ SINK �(� ciTY TEL.NO. d
I certify that in the performance of the work for which this DISHWASHER QD ^ � O �
permi[is issued,I shatl not employ any person in arty manner CONFRACTOR �
SU a5 to beCome SubjeCt to the VJorkzrs'Compensation Laws. CLOTMES WASHER Q� qDORESS u�C 0 a
llate Applicant G 3 3 " f- 1
SWIMMING POOL RECEPTOR V
NOT[CE TO APPLICANT:If,after making this L'ertificate ot CITY � �� TEL.NO.6 y��� V
Exemp[ion, you should become subject to the Wnrkers' LRWN SPRfNKLER SYSTEM � CL
STATE �IC. �� j
Compensatian provisions of the La6or Code,ynu must forth- yyqTER HEATER LICENSE No.�.�y �� CLASS G�3� � }
with compty witk such provisfons or this permit shail be Q� — }
t
deemed revoked. I GAS SYSTEM��OUTLETS nQ DISTRICT NO. PROCESSED BY �
.�-l3CENSED CONYRACTORS DF?CLARATION OU7LETS OVER � ��yt</
I hereby affirm thst 1 am licensed under provisions oY Chapter � 5 PER SYSTEM !1 u
9 (commencing w�ith SectiQn 7000}of Division 3 of the Busi- /' PtNAL '
ness and Professions Code,and my license is in full force and / W'vt o- f�Q DATE ��, g �3 VALIDATION �
effect.
vuaf Ocl ij
License Numher� L�c.Class �—�� FINAL '
/ �or.- •. „ 1[) BY �
ContractorSSaGci�`i�x_�, Date �^/2'�Z �
� I am exempt from the licensing requirements as I am a Plan check fee �
licensed architec[ or a registered prufessional engineer i'7
acting in my professionai capncity (5ection 7051, Bus- PWMBING PERMiT ISSUING FEE§ �V
incss and Profeui�ns Code). TOTAL FEE I
� '
Lic.or lLeg.No. Oate Plan check applicant �
HOME OWNER-BUILDEA DECLARATION Name �� $'Z C�'A ;
[ hereby affirm that I am exempt frnm the Contractor's Address �� �,� ��Jr �
License Law Por the following reason (Section 703I.5, Eusi- C�ty Tel.No. � �
ness and Prufessiuns Code): � • � � 7 5
� I,as owner of the property,am exclusiveiy contracting �
with licensed contractors to construct the project • � � t �.5 0�
(Sectiun 7044,Business and Professions Code). I
03�1 2-82
CONS7'RUCTION LEND1NCi AGIiNCY �
I hereby affirm tha[ there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec.3097,Civ.CJ.
Lender's Name �
Lender's Address �
I certify that I hxve reud this application and state that the �
above information is rorrect.I agree to comply with ali County SEE REVF:RSE FOR EXPLANATORY LANUUAGE
ordinances and State laws regulating Plumbing, and hereby �
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes. ��
. �'�.c�r..�../r.L,., ii�l�.. '��/1`82
S'ignature of Permiitee Date j
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