HomeMy WebLinkAbout0882A (4) WORKERS'COMPENSATION DECLARATIQN qPpLICATlON �OR PLUMBIi+iG PERfifiiT �
f herehy aff'�rm that I have o certificate of consent to self �bqy��q . �
msure,or a certificate of Workeri Compensntion Insurance, CEBU(RFV.t0/Bt)
or a certified copy Ihereof(Sec.3800,�Lab.C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
POolicy No. Company - �
Certified capy is hereby furnished. �
❑ POR AP�fCANT TO fltL IN(PftINT OR TYPE) BUILDING . � �
Certified copy is filed with the county building inspec- ADDRE55 � � �'�/ /
tion depariment. NUMBER FIXiURE OR ITEM p� FEE
LOG4lITV
Dote Applicvn� wATERCtOSET A CN �
NEAREST �
� CERT�FICATE OF EXEMPTION FROM WORKERS' BATH TU8 CRO55 ST. 6
COMaEN5ATt01V INSURANCE SHowEtt �'�'�R �f�pj,Ff " t
(Tkf�aoc►fan nNd not bo comploiod li tbr worh Fnrol�ed 6y �L �
th�p�rmk Is lor oiw iwndred dofMrs(3100}or les�.} [qvnioRv ADDRE55 ,�j,� 1
I certify that in ihe performance of rha work for which tFis
permit is iss�ed,t shall noi employ any person in any manner SMK GTY TEL N07,��r9 �
� so as to become subject to ihe Workers'Compenzation laws. DISHWASHER �
�y. � CONTRACTOR L��/C/l
, Dote � 1 ppliCont -'� CLOTHES WASHER qDDRES$
. NOTI E TO APPLICANT: If, a4ter making this ertificate of SWIMMiNGaOOLRECEPTOR ��
Exemption, you should become subject to rhe Workers' Ctrv '
�. Compensalion proviiians o41he labor Code,you must forth- LqWN SPRWKIFR SYSiEM TEL NO. �
. wifh comply with such provisions or this permif sholt be STATE ���, �
deemed revoked. . WATER NEATER LICENSE NO. ��,q5,5
• LICENSED CONTRACFORS DECIARATION . DISTRiCi Np. ESSED BY �
. t hereby offirm that p qm Ifcensed uruler provisians of Chapter 9 � �+5 SYSF€M pUTlE75 \ � �
(commeru�ng wkth Section 7000}of 8'wksion-3 0#the$usiness OUTLEf50YER t
ond Professions Code,ond my license is in.fu!!force and effec�. 5 PER SVSTEM � 7� �
oare YAIIDATiON � i
License Number Lic.Class . V �
FINAL oC �
Contrac�or Date BY Q
u �
❑ I am exempt under Sec. W
8.8P.C.for ihis reoson , H !
Plan check fee y����ti�,t��—�— Z �
6a�e: ��� LL-- �
PLUMBfNG PERMIT ISSUING FEE$ �
Signature
TOTAL FEE �,� �
� ��t1�rl t_i] VCJ irn'�'�:;.....:<, i
Plpn[heck applimnt � ~� `
� $INGIE FAMILY -
HOME OWNER-BUIIDER DECLARATION Name �,� � i
I here6y affirm that I am exempt from the Contracror's license "��v ,
law for ihe following redson(Sectian 7037.5, eusiness and Address � .� �C fi�C H
Professions Code): �i}y Tef.No. `��r � � {i�
� � . . . . .5 ,
1,as owner of ihe property,wif!do the work and ihe
structure is not intended or offered for sole(Section
7044,Busines5 and Professions Code). � � � • • � 6.Jr� .
CONSTRUCTION LENDING AGENCY � -• • •� Cz S C�
� I hereby affirm�hot there is p construction lending agency for � .
; the performance of the work for which ihis permit is issued ��]G� �8 5 �
� (Sec 3097,Civ.C.). �
Lender's Nome ��
� tender's Address �
I certify�hot I have reod this application and stare ihat the � �
obove info�molion is correct I agree to romply wi�h all Caunty
ordinances and Siate laws regulating Plumbing,and hereby .
authorize represenfa�ives of this County ro emer upon fhe .
above-menfioned praperty for inspeclian purposes.
� � 2,�� SEE REVERSE FOR EXPIANATORY LANGUAGE
ignature of Permittee Data
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