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. �
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