HomeMy WebLinkAbout1052A (7) � WORKERS'COMYENSATION DECLARATION 7U6NA �
hereby affirm that I havn a certificete of����t to se,� �E.,�,=_.o, APPLICATION FOR PLUMBING PERMIT �
sure,or a cartificate ot Workers'Cumpeasation(nsurance,or ..
certified copy thereof(Sec.3800,Lab.C. .
COUNTY OF LOS ANGE LES BUf LDING AND SAFETY
olicy No. Company . � � �
CeriifieJ copy is hereby furnished. FOR AP?LICANT TO FILL IN(PRINT OR TYPE1 BUILUING �. �� � ��
p..� ADORESS
�y) Certitied copy.u filed with lfe c�un 4i 'ng inspectiun NUMBER . FiXTURE OR ITEM � FEE
�"r �ep� tm nt. � . WATER CLOSET- � LOCA.IYfY .._ ..._ - .` �(�� �'� . .. .� .
lUate����ADDlicant ^ _ NEARE87 __ .. ,. ... -
.... &AFH.ZU6 _..... ... . . . .. ...... ..... .. ��. .:..:... CR05SSt: ..... .... .. .�...... . .. .
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CERT[FICATE OF EXEMP'fl FROM WO1tKERS' � - � �� � � � � �
COMPENSATION ENSURANCE . SffOWER � � � OWNER� � -' �� �
LAVATOR4 MA{L �1
(Tliis section need not be completed if the wotk invotved ,aooRESs ��O _ O �
by ihe permit is for one hundred dollars (SlOU)or less.) SINK
CITY � � 7EL.NO.��: U
f certiPy that in the performance of the work for which this OISNWASIiER �
CONTRACTOR
pezmit is issued,i ehstl nut emptoY any person in any manner _. ` O
so as)t co e subject fo th �- rker m ensation Laws. CLOTHES WASHER pDDRESS �_ U
Datu� Applican � � - SWIMMING POOL RECEPTOH OW.
MOTICE TO APP�fCAN7:I[,afte aking this Cer[ificatc ot CITY TE�.NO. Vi
Exem tion, ou ahoold become subjec[ tu the Workers' LAWN SPflINKIER SYSTEM Z
P Y [� c
ComDensatinn provisions of the Labor Code,you must forth- � AT p�, a�� CLA55
with comply with .cuch provisio�s or thie pnrmit shall be � WATER HEATER I LICENSE NO. �
deemed revoked. GAS SYSTEM OUTLET3 DkSTRICT IVO. PROG ED BY i
LICENSED CONTRACTORS DECLARATLON OUTLETS OVER �� '�-'��� �
i hereby effirm thal I am licensed unde�prorisiuns of ChaDter 5 PER SYSTEM '
9 (commencing with Section 7000)ot Division 3 oT[he Busi- fiNAL �a�� /�/ VALIDATIDN �
ness and Professions Code,and my license is in full force and OqTE t
effect. /
('� FIfVA
License Number ��� Lic.Class ��` BY � �y�J �
Contructor Dat� � �
� � I am exempt f m ihe licensing re4uirements as I am a Plan check fee j
. . ticeased� ncchitect or a registered pmfessional enKFaeer ,
acting in my professionek capacity {Setli�n 705t, Bus- PLUM8ING PERMIT ISSUING FEE$ � i
iness and Professions Code). TOTAL FEE 2 7� �
f1052A �
Lic,ur Reg.No. Date Plan check applicant �
#•• • • •5 .
HOME OWNEN�$UILUER DECLARATION Nama q
• �
I hereby aff'um that I am exempt Prom the Contractnr's Addresc I t G= i
License Law for the following reason (Section 703I.5, Busi- GitV TeL No. � � �� �5 Q� �
ness and Nrofessions Code): �
� 1,as owner oF the property,am exclusivety cont[acting '�'� �_8 t
with licensed cuntractors to coastruct the project � i
(Section 7044,Business and Professions Code).
i
CONSTRUCTION LENDING AGF.NCY �
1 herehy affirm that there is a wnstruction lending agency
for the performance of the work fur which this permit is .
issued(Sec.3097,C3v C.). . �
Lender's Name
Lendu's Addreas �
1 certify ihat 1 have read this application and st�fe that tUe
ahave intormation is correct.[agree to comply witfi atl Caunty SEE REVERSE FOR E%YLANATOILY LANGUAGE
utdinances and State Iawa regulatlng Plumbing, and herebY �
�authurize representatives of this County to enter upon the
�abov ntioned operty tor inspectinn purposes.
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ignat of Permittee Date �
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