HomeMy WebLinkAbout1372A WORKERS'COMPEN5ATIONDECLARATION �BAe•�A qpPLICATtON FOR PLUMBING PERMIT �
[ here6y affirm�at I have a'certificate of consei�t ro self cs sn�z-ea�
insure,or e cri�tificate of Workers'Compensation Insurance,or �
e certiEied y�.pv tQereot�;£3800, C.)' • COUNTY OF LOS ANGELES BUILDtNG AND SAFETY
},, � `1`
Policy Now� �ompany
f �Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ���yJ
� CerNPied copy is tiled wilh the rounty 6uilding inspection
NUMBEfl FIXTURE OR ITEM � FEE ADDRESS O � L� / ti•
e artme WATER ClOSET �OCALITY
pate�pplicant NEAREST � �
BATH TU9 CROSS ST. `
CERTIFLCATE OF EXEMPTlON FROM WORKERS' SHOWER � r �C`��c„
COMPENSAT[ON 1NSURANCE OWNER
LAVATORY . MAIL /, }
(This section need not be completed if the work involved aooaEss O y I[1 a
� by the permit is for one hunJxed dollsrs ($100) oc leas.) S��K �
CtTY � � TEL.NO. U
I certify that in the performance of the work for which this DISHWASHER �
r permit is issue+i,I shall not empiny any person in any manner
CONTRACTOR
] so as to bewme subject to the Workers'Compensation Iaws. CtOTHES WASHEH ppDFiESS g U� ' �� �.0 �U �
� Date Applicant
� � SWIMMING POOL RECEPTOR CITY � TEI..M . � �
, NOTICF,TO APPLICANL•If,after making this Certiflcate of
Exemptian, you should 6ecome subject to the Workers' LAWNSPflINKLERSYSTEM STATE Lf0. / Z
Compensation provisiana of the Lu6or Code,you must forth- WATER HEATER LICENSE NO. l � ClASS T� �
with camply with such ptovisions or this permit shall be �
deemed revoked. GAS SYSTEM OUTlETS DISTRI T M1fO. PROCESSE�BY
LICENSEDCONTRACTORSDECL.0.RATION OUTLETSOVER `� � Q �
' I hereby affirm thef 1 am licensed under Qtt>visions of Chapter 5 P R SYSTEM
4 (eommencing with Section 7000)of Dirision 3 of the Husi- FINa� s
1
ness and Professions Code,aod my license is in full force and ✓ � �� DATE 3—['��Z- VAUDATION f
effecT. :
�/ FtN L �
License Num6er � ��� Lic.Ciass ���'�y BY
�. Contractor��L�R� Date 1 Z' �
� I am exempt from the licensing requicements as 1 am a Plan check fee �
licensed architect or a registered professiunal engineer pLUMBING PERMIT ISSUING FEE$ � (
acfing irt�my p%fessionat capacity (Section 7051, Hus- �
� iness and Rofessivns Code). TOTA�FEE � �
Lic.or Keg.No. Da[e Plan check applicanc �
HOME OWNER-BUILDER DECLARA170N Name . ' �
z137,2A
I herehy affnm that i am exemP� from the Coniractor's Address
� License Law for the following reason(Section 7031.5, Busi- ��tY Te1.No. #�� • • �5 �
j ness and Professions Cude): I • • 1 2.5 0
J {,as owner oF the propertY,am exclusively contracting �
I � with licensed contractots to construct the praject • • •� 2 5�� ;
(Seciion 1044,Business and Professions Code). J
Q�.2P/�82 1
� CONSTRUC710N LENDING AGENCY �
I hereby aff'um thttt thece is a construetion lending agency �
for tLe performance af the work for which this permit is
issued(Sec.3097,Civ.C.).
Lender's Name . k
Lender's Address �
I rertify thnt I have read this application and state thaf the �
above information is correct.I agree to comply with all Caunty SEE REVERSE FOR EXNLANATOftY LANGUAGE 3
ordinances a�d State laws regulatfng Plumbing, and hereby !
authorize representatives of this County to enter upon the �
above-mentioned Property for inspection oses. �
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Signat f Perm tee- Date �
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