HomeMy WebLinkAbout1585A (9) WORKERS'COMPENSAT[ON DECLARATION �awsuw �
1 hereby affirm that 1 have a certificate of consent �o self =e.��,2.eo, APPLICATION FOR PLUMBING PERMIT
insure,or a certificate ot Workets'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.}
CQUNTY OF LOS ANGE LES BUILDING AND SAFETY
Policy No. Company ' •
� � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUIIDING �y
A��RESS �p �rC /�� w C � �
�Cer[ified copy is fited wi e cou bu'Idin pection NUMBER FiXTURE OR ITEM • FEE
LOCALI7Y
�iepart�e � WATER CLOSET �Q
DateX�� �ApDlicaDt — gqTHTU6 �a CROSSST. '�' LU i
CERTlF[CATE OF EXtiMPTION FROM WORKERS' � �
COMPENSATION MSURANCE SHOWER � OWNER ��� �prR.�2oN S
LAVATORY MAtL n
(This section need not be completed if the woTk involved U qooREss ���(p /�/ `Y •Lr-- � �
by the permit is for one hundred doltus (SIOD) or less.) SINK
CITV TEL.NO. ��3�
I certify that in the performance of the work fur which this �ISHWASHER U
permit is issued,[shall not employ any person in any manner d� CONTRACTOit � Z � '
so as to trecome subject to the ltorkers'Compensation laws. CLOTHES WASHER ¢
�� ADDRESS ,�y�Q O !
Date Applicant SWIMMING POOI RECEPTOR �� �
NOTICE TO APPL[CANT:if,aftec making this Certificate of CITY TEL.NO. W �
Exemption, you should becume subject to the Wnrkers' r LAWNSPRINKtERSYSTEM O� STATE �y �IC. Q �
Compertsation provisions of the Lebor Code,you mus[forth- yyA7ER HEATER LICENSE NO.. �'� �—/ CLASS /J � Z
with comply �vith such prorisions or this permit shall be d� — !
deemed revaked. GAS SYSTEM OUTLETS O O DISTO NO. �OCESSED B� �
G[CENSED CONTRAC"{'012S DECLARATtON OUTtE75 OVER
�
T hereAy affirm that I am licensed under provisions of Chapter 5 PER SYSTEM OU �- �
9 (commencing with Section 7000)of Division 3 of thz 8usi- F��p`� VALIDATION �
ness and Professions Cude,anQ my license is in full foree xnd DA7E / �� ��
etfect.
License Number �� Lic.Gass � s _ FINAL
BY 3
'ontractor �✓��3nJ Dute ���B�"'8Z
' [am exampt f�om the licensing roquirements xs I am a Plan check fee
IicGnsed a[chitect or a registefed prufessiunal engineer pWM81NG PERMIT ISSUING FBE§ � CJ
�aetl�g in my profeasiona[ cipYcity (Seetion 7051,Bus-
iness and ProYessions Code). TOTAL FEE '
C.ur Reg.No. Date Plan check applicant �
HOME OWNER-BUILDER DECLARATION ' Nama D � � s`C*�
1 hereby�rff"vm that 1 am exempt from the Cuntractur's Address L ����5 p
�icense Law for the foflowing reason (Section 7031.5,Busl- I City Tet.No. .�' '� #� � • • •5
iess and Professions Code): -
Y�,(�as owner of the propeRy,am exctnsively contracting �� �-• � � �l J�Q
witN licensed contractors to construct._Jhe pioject ;�
(Sectiun 7044,Business and Professions Code). j !• � � (x 5.0 v
CONSTRUCTION LENDtNG AGENCY � O 2� $"$2
hereby aff'vm that there is a conatruction iending agencq �
r the performance of the work for which ihis permit is �
ued(9rc.3097,Civ.C�QN �
nder's Name I
der's Addrass �
•tify that I hnve read thes applicetion and state[hat the
:information is correct.I aQree to compky wilh all County SEE NEVERSE FOR EXPLANATORY LANGUAGE
me � ��nd Stxte laws r a ng Plum6ing, and hereby �
nze repre tati s thi ounty tu enter upun the -
menxioned ro or spnction purposes.
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