HomeMy WebLinkAbout1601A (9) ._— , �,
'� WORKERS'i:OMPEN3AT10NDECLARAYION �c�s��w � I
,Aereby affirm �he� � �eve a��«E�,��ete of�a��t to se�f «.,,��-.o, APP,LICATION FOR PLJNiBING PERMIT
��sure,ot u certificatn of Wurkers'Compensation tnsurance,or ...-- . .. - � � - � � � �"
cerNfi d copy thereoP(5ec.3800,Leb.CJ � ' - ' , �
w��y-a9G 5%5 � COUNTY OF LOS ANGELES BUILOING AND SAFETY
� Policy No. Company�,���'� .
I � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN IPRINT OR TYPEI BUILDING��/� p.�.fl,n�, d���
ADDRESS � ����� �C'
� Certified copy ic fled with the counfy buildi g inspection NUMBER FIXTURE OH YfEM • FEE ,
�-epar1 WATER CLOSET LOCALfTY�" �
➢ate ✓ � ADP��cant NEAREST / AA �,/ �
BATH TUe CROSS ST. � ��G�G�/�ry (
CERYlF[CATE OF EXEMP'FION FROM WORKERS'
COMPETiSAT10Pi INSllRANCE SHOWER OWNER /���yd`j/�'�
LAVqTORY MA�� 6�,,��/� �
(This section need not 6e completed if the wock invulved qooRESS 7G'J'G°7C� �
6y the pennit is foc one hundred Jollazs(SI00)or tess.) SINK }
GITY� TEL.NO. O 1
1 ceKify that in Ihe performance of the work for which thi5 DISHWASHER U '
permit is i&sued,[ahall pot emplay any person in any manner CONTFACTOq
so as to become su6ject to the Workers'Compensation Laws. CLOTHES WASHER �/���/,7 �
AD�HESS �.T�.7 O
Date Appiicant V—
SWIMMING POOL RECEPSOR
NOTICE 1'O APYLICANT:tf,after making this Certificate uf CITY � TEI.NO. W
Ezemption, you shou{d bemme suhject ta the Workers' LAriNSPRINKLER5Y5TEM ��//' /� a.
Compensation provislons of the Labor Code,you must forth- �ICENSE N0.`V'V � �L C ASSFI'� Z
with comply with such provisions or this permit shall 6e WATER HEATER 9 �
deemed revoked. � �� DISTRICT NO. PROCES3ED BV
GAS SVSTEM OUTlETS �'7
LICENSED CONTRAC'CURS DECLARATION pU7�ETS OVER f`�
1 hereby afP¢m that 1 am licensed under provisions of Chapter 5 PER SVSTEM a"�'�`��� �
� 9 (commencing with Sectiun 7000)ot Division 3 of the Busi- FINAL �,
ness and Rofessinns Cade,and my[icense is in full force and � d��l 4ATE � �pZ �a VALIDATION �
effect. /�
r, 1 � fd'�/ FINAL
License Numbr� I Lia Clasa gy
ContraCto/Y�-Y� Date �+���4
� 1 am exempt from the licensing requiremen[s as i am a PIaR CheCk fgE �
ticensed architect or a registered Drofessional engineer pLUMe1NG PERMIT ISSUING FEE$ � �
acting in my proPessionel Capacity (Section 705t,6ur �
iness and Professions Code). TOTAL FEE ,� � �
Lic,or Reg.No. Date Plan c�eck applicant ! /
/%f�•
HOME OWNER-BUILDER DECLARATION Name � �
I hereAy affum that 1 xm exempt Prom the Contractor's Atldress
I,icense Law Far the toilowing reason(Sectiun 7031.5, Husi- City Tel.No.
ness anJ Protessiors Code): �
� 6 as ownet of the property,am exclusively contrae[ing
with licensed rontractars to construct the projeet
(Section 7044,Business and Professions Code).
CONSTRUCI'ION LENDING AGENCY �
1 hereby affirm that the[e is a constcuction lending agency t
�� �Q.� ht
for the performance of the work for which this permit is �
issued(Sec.3097,Civ.C.)./1/�- '
Lender's Name �-��� f'� � � � �" �
Lender's Address � • • � .:,U� �
�
I certify that [have read this applicatiort and state that Ihe • c c � ?,Ct J�
above information is correct.I agree to comply with ail County SEE REVERSE FOR EXPLANp'IORY LANGUACE `
ordinances and State laws mgulxting Plumbing, and hereby ��.� J�..�C
authorize reprezentatives of this County to enter upon ihe
above-me �oned prop�f�ty�fo�r in�sp.ection purposes. -
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