HomeMy WebLinkAbout1606A (15) � WURKERS'COMPENSATION pECLARATION �ews��w �
I hereby affirm �hat ► he�e a certificate of consent to se1C �E.,�,=-.., APPLICATION FOR PLUMBIIVG PERMIT �
' insure,or a certificate a}Workers Compensation Insurance,or
. a certified copy thereof(Sec.3800,Lab.C.)
� 5?'+`;37 State ��m Funr.'� COUNTY Of LOS ANGELES BUILDING AND SAFETY
� Policy No. Company ,����•P•
� � Certified copy is hereby furnished. POR APPLICANT TO FILL IN(PRINT OR TVPE) BUIIOiNG
Q Certi£ed co u filedwith[he count buildin NUMBER FIXTURE OR ITEM • FEE ADORESS 2���7 i'OC�.j '•i�.P,T
' pY' y ginspection
� �le�art ent. t IOCALITY '3_a��PC� R3T
E1 O}lu^ � plo^ �•`?• WATERCLOSET
% llate �� � Applican[ �../ NEAREST
� a'` BATH TUB CROSS ST. t'="_ =+��1= �`�.
CERTIFICATE OF EXEMPT70N ROM WORK'RS'
t COMPENSATiONINSURANCE SMOWER OWNER J�hn Goolsb
LAVATORY MAIL
(This sxHon need not be completed if the work imolved AODRESSi3�+31 Doty Ave, d
` by the permit is for one hundred dollars(3100)or less.) SINK �
ciTv i��athorne TEL.NO.Cl]!1_45zZ U
€ I certify that in the performance of the work for which this DISHWASHER O
permit is issued,i shall not empluy any person in any manner CONTPIACTOR i�3.Ot1�. �OO�.S
� so as to become subject to the Workers'Compensation Laws. CLO7MES INASHER ADDRE5S17Q17 ';. i T2:1Ci SCyU�t.0 U
9 Date Applicant Q � �
1 SWIMMING POOt RECEPTOR
fi NOTICE TO APPLICANT:If,after making this Certiflcate of C�TV"��I@SL COS*� :lu :�I.��1 TEL.N0.9S'L_I77[� N
p Fzemption, you should become subject to the Workers' LAWNSPRINKLERSVSTEM STATE n � LIC. z
� Compensetinn provis3ons oP the Labor Code,yov must fnrth- LICENSf NO. Z"���'� CLASS �'S3
with comply vrith such provisions or this permit shetl be WASER HEATER
_ deemed revoked. �. GAS SVSTEM OlJ7LET5 OQ DISTRtCT NO. PH CESSED BY
L(CSNSED CONTRACTORS�ECtARATION OUTLETS OVER �O� �G.�-�
� I hereby affirm that I um licensed under provisions of Chapter 5 PER SYSTEM �
; 9 (commencing with Section 7000)of Div�sion 3 of the Busl- y FINAL �
` ness and Prnfessiuns Code,and my license is in full force and �ti�5`�Di10R �+r1iV2 �Q �ATE � 8 VALIDATIflN
° effect, �
� FINAL
� LicenseNumb�r L''���,'� Lic.Cfass �-[� aY -�•� .
� ///'''��_�"""_D:," c00 , i>?; /
� Con[ructpy�/ D te �!���2
� ���
[ � I am axe pt from t e licensing requirements as (am a Plan check fee
3 licrosed architect o* a registered professionai engineer pLUM81NG PERMIT ISSUING FEE$ ��
acting in my professional capacity(Section 7051, Bus- l
; iness and Protessiona Code). TOTAL FEE '�ff O ,�.� �Q,(�A
� Lic.or Reg.No. �ate Plen cneek applicent S
� �ja • • • ��
� HOME OWNER-BUILDER DECLARATION Name.,,�'O��a pn�']�
i • •zo5�
naaress?7Q19 i3. �'rancisquiCo
. I hereby aff'vm that [ am ezempt from ihe Contractor's • • •2�,J U�
, License Law for the following reason (Section 7031.5,Husi- City[yT�g� ^pqt ng gi 791 rei.No. 9b?-1779
�� ness and Proftssions Code): . a G� a��1 z
� I,as owner o#the property, am exc{usively contracting
with lirensed contractors to construM the project
(Sectibn 7044,Business and Mofusions Code).
CONSTRUCTION LEND[NG AGENCY
I hereby eFfirm that there is a construction lending agency
' for the performance of the work�for which this permit is
� issued(Sec.3097,Civ.CJ.
i Lender's Name
i Lender's Address - �
� I certify that 1 have read this application and state that the
', above information is correct.I agroe to comply with all County SEE REVERSE FOSI EXYLANATORY LANGISAGE
ordinances and State Iaws reaulating Plumbing, and hereby
authorize representa[ives of this County W enter upon the � .
above-mentioned p operty f inspection purposes.
, � "t2
Sign tu f Permi[tze �ate .
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