HomeMy WebLinkAbout1148A (9) WORKERS'.COMP£NSATION DECLARAT[OP3 �� »�os�w ��-ji
I hereby ef��m tha� , he�e a certificate otconsent to self � cE..,,._so, APPLICATtON FOR PLUMBlNG PERMIT �
insure,or e certiflcafe ot Workers'Compensation Insurance,ar .
a certified copy thereof(Sec.3800,Lab.C.) � � �
�n�np�dC FREMONT INDEMNITY COUNTY OF LOS ANGELES BUiLDING ANDSAFETV i
PolicY No..G3Li][.YYHMnpanY �, .
�
� � Certified ropy is hereby fumished. FOR APPLICANT TO FI lL W(PRiNT OR TYPE)- BUILDfNG � � � �
�Cer[ified cop ia filed with th ,County bu' !ng i pection NUMBER FIXTURE OR ITEM • FEE AOOFiESS
depart e t. / ; WATER CLOSET LOCALI7Y
Dstc ' �Applican't ' NEAREST
9ATH TUB CROSS ST. � ��'K' I
CER IF1�ATE OC EXE 1PTlON FAOM WORK£RS' -
COMPENSAT[ON INSURANCE � � SHOWER OWNER
LAVATORV MAIL 'tZ1�L7 RIMFIRE �
(This section need not be compieted if the wo�k involved AODReSs d
by tlie permit is foc ane hundred Jo{lazs (5100)or tess.) S�NK
. dTY DIAMOND BAR TE�."0.594-862 V
I certify that in the performance oP the work for which this DISHWASHER � � �
perrtit ic issued,t shaF}nat employ anY person in any manner CON7RACTOR �
so xs to become subject to ihe Wbrke[s'Compensatiors Laws. CLOTHES WASNEIa F
aooaesQ145U GOLDEN SPRINGS c� I
Date Appticant � SWIMMING POOL RECEPTOR a �
NOTICE TO pPPLlCnNT:[f,after making ihis Certificxte of CITY w��Ur� TEL.NUS,gS-7547 N
Ezemption, you should become subject to the Workers' LAWN 5PRINKLER SYSTEM STqTE LIC. �
Compensation provisiuns of the Ln6or Code,you mutt forfh- LICENSE NO. CLASS �j3 �
with comply with such provisions or this permit shalt be WATER HEqTER
deemed revoked. GAS SYSTEM OVTLETS DISTRICT NO. PROCE93E0 BY
oa �
LICENSEDCONI'RACTORSDECLARATION OUTLETSOVER ��/ �
1 here6y affirm that[am licenced nnder provisions of Chapttr 5 PE R SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- ��Np� VALIDATION �
ness and Professions Code,artd my ticense is in full force and f" P�N� DATE � � 8� �
eLfec[. �O f �� , `v _ Q� �
FINAL
License Number - Lia Class � 'S BY
Contractoc � lDate Y �
� I am exempt from the lieensing reyuirements�s I am a Plan check fee � .
licensed architect or a regis[ered prafeasioaal engineer pLUMBING PERMIT 13SUING FEE$ �l� s
aciing in my professioaat capacity(Seetion'i051, Bus- � �
iness and Professions Cude). TOTAL FEE (p l0 �
J
5
Lic.or Reg.No. Bate alan check applicant €
HOME OWNER�BUILDER DECLARATION Name ��UT POOLS
Addresc 2145d GOLDEN SPRILdGS � �> > �$A �
t here6y af£am thxt I am exempt Prom the Contractor's .
License Law for the followi�g reason (Section 7031.5,Busi- City T Tet.Na. � #• • • • • 'rJ �
ness and Rofessions Code)= �
� t,as uwner of the property,am exclusively contcacting � • •1 b 5 0 �
with licensed coniractors to construct the project = `
(Section 7044,Business and Professians Code). . • ��� �5�� �
CONSTRUCTION LENUING AGENCY ��L 2 9�$.� �
I hereby affirm that there is a construction lending agency
for the pertotmance of the work for which thia permit is
issued(Sec.3097,Civ.C.). �
Lender's Namo +
LendePs Address
I certiPy that 1 have read this appiication and state that the
above information is correct.I agree to comply with all County , SEE REVERSE FOR EXPLANATORY LANGUAGE
otdinanc and State laws regulating Ylumbing, and hereby .
auth�ry�represen veS of this County to enter upon the
�b�fnentioned opert for inspection purposes.
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