HomeMy WebLinkAbout1663A 4! W02KER5'COMPENSATIONDECLARATION �ucvw pPPLiCATiON FOR PLUMBI{�G PEFtMtT �
[ hereby aftirm that [ have a'certificate o(consent to sei[ ce eV(z-eo)
insure,or a certificate of Workers'Compensation tnsurance,or
i a certified copy thereoT(Sec.3800,Lab.C.)
i COUNTY OF LOS ANGELES BUILDfNG AND SAFETY
! Policy No. Company
� � CertiCied copy is hereby furnished. FOR APPLICANT TO PILL IN(PRWT OR TYPE) BUIL�ING � � ��/ J/�
AOOflESS '1' (/
� � Certified copy is�led with the county building inspection NUMBER FIXTURE OR ITEM � FEE
` department. WqTER CLOSET bD LOCALITY � - '
; Date Applican[ NEAAEST
BATH TUg � '� CROSS ST. �
f CERT[F[CATE OF E%EMPCION PROM WORKERS' OWNER
- COMPENSATION INSURANCE SHOWER �'D �
� (Th15 SCctiOn need not be completed if tne WO[k IlrvOlved LAVATORY � pDDHESS /� 6�
! by the permit is for one hundred doIlars (5100) or less.) }
SINK Q� C�TY � TEL. O
y !certify that in the perfotmance of the work for which this o15HWA5HER rr � . V
- pzrmit u issued,[shatl not employ any person in any manner T CONTRqCTOR
9 so as to become sub'ect to the Workers'Com ensation Latvs. ..n �
J P , CLOTHES WASHER y.+ ADORESS � ��S�L�}-a� O
�3 Date Applicant SWIMMING POD�RECEPTOR U
' N0710E TO AYPUCANT:lf,after making this Certificate of CITY TEL.NO�'�� W
� F.zemption, yau shuuld become subject to the Workers' LAWN SPRINKLER SYSTEM �'
Compensation Orovisions of the Labor Code,you must forth- STAT p LIC. y
� WATER HEATER LICENSE N�`�3�� CLA55 C��S'� z
awith comD�Y w'1th such provisions or this permit shatl be
DISTPICT NO. PROC ED BY
deemed revokad. / GAS SYSTEM OUT�ETS (�
i LICENSEDCONTRACTORSDECLARATTON OUTLETSOVER � �
� I hereby atfirm that I am licensed under pro�isions of Chapter 5 PER SYSTEM
9 (mmmencing with Section 7000)of Oivision 3 of the Rusi- FINAL VALiDAT10N
� ness and Professions Code,and my ticense is in fu13 furce and DATE
etfect. �7
7 / 2� FINAI
� License Numbe� "�Lic.Class 4`" ✓� 8Y
fContractorl��� Date �-` �I`�Z_. .
i � I am exempt from the licensing requirements as I am e Plan check fee
A licensed architect or a registered professional eng3neer pWMB�NG PERMIT ISSUING FEE S � �1 6 5�3 A
� acting in my professional capaciry (SeMiun 7051, Bus-
� iness and Professions Code). TOTAL PEE �j �• • • • •5
� Lic.or Reg.No. Date pian chack aPplicent � • •9 C�5 0
± HOME OWNER•BUILDER�ECLAAATION Name �� ��)�5��
I hereby afEvm that [ am exempt from the Contractor's Adtlress ���v�$2
Liccnse Law for the following reason (Section 7031.5.Busi- City Tet.No.
nxss and Professions Code):
� � 1,as owner of the property, am exclusively coM�acting
� with licensed contractors to construct the projett
� (Section 7044,Business and Professions Code).
�
� CONSTRUCTION LENDING AGENCY .
iY hereby affirm that lhere is a construction landing agency
for the performance of the wark for which [his permit is
� isxued(Sec.3097,Civ.C.).
Lender's Neme
� Lender's.Address �
i cerf at I have read this application state that the
ebov infu ation is correct.1 to co Y with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordin nce and State laws gufa'n bing, end hereby
autho'z representatives o this y to en4er upon tAe
ebove- ntioned property or' on pur es.
� Sig atu e of Per i[ e Date
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