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HomeMy WebLinkAbout0908A (4) WORKERS'COMYENSAT[OND�CLARATION ]lA66]A APPLIGATION F�R PLUMBING PERIviIT � [ hereby affirm that I have a cart�ficate of consent to selt ce a�v(¢-ao� insure,or a cerdficate of Workers'Compensation[nsurance,or a certified eopy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGE LES BUI LDING AND SAFETY Pnlicy Nn. Cnmpany � � Certitied copy is hereby furnished. FOR APPLICANT TO FlLL 4N(PflINT OR TYPE) 9UILDING � � ADDRESS � Certified copy is filed with the county building inspection NUMBER FfX"fURE OR ITEM � FEE deQariment. IOCALITY � WATER CLOSET Date Applicant NEAREST , BATH 7U6 CROSS 3T. \QJ CERTIFICAT,E�OF EXEMPTION FAOM WORKERS' � �MPENSATiO NCE SHOWER OWNER O � LAVATORY MAIL � (This aectio need not be cpmploted if th wock invotved ADDRE55 Q by t17e pE �t iS fOr ona htltldtEd dollars !00)OI IeSS.) StNK CIFY TEL.NO. U : [certify tha in the performanC�e of t�e wor for which this DISHWASHER � � permii i issu ,[shall i e ny sny erso in any manne[ CONTRACTOR r� O sp as to bec subjee to the ' o pensuli�n Laws. CLOTHES WASHER qDDRESS U Uate Plic t .. � .. _ �. ((.�.. n. � SWIMMFkG POOI RECEPTOfi NOT[C�T APPL(CA Ti- . �a m is Certificate of CITY TEL.N !� tixemp on, you should become subject to the Workers' LAWNSPRWKLERSVSTEM S7ATE -1�} LIC. ^� Z � Compensation provisionx ot the Labor Code,you mus[forth- yyqTER HEATER LICENSE NO. / /(, CLASS C�J with romply with such provisions or this pesmit shall be Q ptSTRIC7 NO. �FjA�ESSEp BY � deemad revoked. G/IS SYSTEM Ol1TLET5 L[CtiNSED CONTRACTOR5 DECI,ARATtON `O , ` OUTLETS OVER �_�CXVi'�� � I hereby affirm that I am lirensed under pmvisions of Chapter 5 P R SYSTE - �'i ('�ommencing with Section 7000}of Divisian 3 of the Busi- � � d �' pAT�� j]��% v�� VALIDAFI�N � ness an fessiona Code,and my license is in full torce and �'`�"'� '� effect. * \. 3 F�NAL �j � Lic up� �r�t��?7 Lic.Class '�J ' /�- ont •to �� Date � � � I am e rom the licensing req irements as I am a Pfan check fee � IicenSed srehitect or a teg�stered professiunal engineer PLUMBtNG PERMIT ISSUING FEE$ �` 4 acting in my professional capacity (Section 705t, Bus� `�� � iness and['rofessions Code). 7OTAL FEE � �jQ �(?�y�.&(''• L'ec,or Reg.No. Date Pian check applieant �v �6 • • • NOME OWNER-BUILDF,R DE',CLARATION Name � • • � 6�Q i heroby affirm that [ am exempt from the Contractor's Address License Law fos the following reason(Section 7031.5, Busi- GitY Tel.Na. � ' � � �'�-v� ness and Professions Code): j f G�_�,� 1 � 1,as nwner of the pcoperty, am exclusively contracting � with licensed contractnrs to cons[ruct the project � (Section 7044,Business and Professinns Code). ; � CONSTRUCTION LENDING AGENCY : 1 hereby affirm that there is a construction lending agency � far the performance of the work for which this permit is � issued(Sec.3097,Civ.C.). ; Lender's Name //C'e er's dress II certi hat I have ead this applica[ion and state that the above in mation is c nect.1 agree to comply with nll County SEE REVERSE FOR F,XPLANATORY LANGUAGE 1 ordinance and Stat laws regulating Plumbing, and hereby auth ri�e r resent ives of this County to enter upon the v mcnti ed p per[y for inspection pur ses. � � �g re of Per �ttee Da � � ! d � } � ,,. =��� - � }.�. 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