HomeMy WebLinkAbout1282A WORKERS'COMPENSATIONDECLARATION APPtICATIOM F�R PlUMBIIdG PERd!!1!T � j
I hereby affirm that t have a cer�ificate of consent to self 7eAyy�q �
insure,or a cerfifimte of Workers'Compensafion Insuronce, CE 817(REV.10/BU 1
or a cer�ified copy thereof(Sec.3600,La6.C.) COt1NiY OF l05 ANGELES BUILDING AND SAFfTY j
P�olfq No. Company �
Carfified copy is hereby furnished.
❑ FORAPPLICANTFOF{LLW�PRINTORtYPE) BU�LDING /�f
Certified copy is filed wirh the county building inspeo- AD�RESS �/✓ � �
Iiondeparfinenf. NUMBER FIXTUREORITEM @ FfE
�ocaim
Date qppli4ont WATERCLOSET NEAREST
CERTIF4CATE OF EXEMPTION FROM WORKERS' BATH Tl1B CRO55 ST.
COMPENSATION tNSURANCE OWNER
(Thts secfion need nof be complNed R}ha work inrolvad by SHOwER
the parmit is for one hundred dollars(5700)or less.) taYATORv MA��
AD�RE55
I certify tFwt'rn the performance of the wwk for which this
permit is issued,I shall not emplay any pe:on in any manner SINK CI7Y �� TEL NO. ^ps
so as to become subject to}he Workers' ompensalion Laws. p��{yyqgHER
'd � CONTRACTOR
Da�e �_.�.�Applimnl CLOTHES WASHER
NOTICE TO APPLI NT: If, after makin t is Cer�ificate af nDDRE55 /�
Exemption, you should 6ecame su6jecl ta tbe Workeri SWIMMINGPCpIRECEPTOR
Compenso�ion provisions of the labor Code,y0v must forth- ��TY r� TEl NO. F�
LAWN SPRINKLER SYSTEM
with compiy with such prorisions or ib[s permit shall be SFATE �7 Q � tfC. �
deemad revoked. WATER HEAFER LICENSE NO. J p�� CtA55
- LICENSE�CONTRACTORS DECLARATION DISTRlR NO. D&Y �
7 hereby offtrm Ihat l om lite=+sed��nder provisions of Chapter 4 GAS SYSTEM. OU7LET5 �
(mmmencing with Section 7000�of Division 3 of the Business pUTLET50YER � u"�-� y' E
and Aofessions Code,and my license is in f�ll force and eHed. 5 PER SYSiEM F��� " 0. �
� DATE yC � �r� VALlDATtON a j
License Nvmber - Lic C�ass �
FiNA �
ContrvUor pote 61" � '
� � �
I am exempt�nder Sec. �
� �„ ;
B.&P.C.for this reason Pfan check fee - - g
�ate: �
PLUMBtNG PERMiT iSSU4NG FEE$ ��J � f
Signoture �
TOTAL FEE �� (1 � } ����
5
Pian check appficont i;• • • • °rJ �
SINGLE FAMtLY ' f
HOME OWNER$UILDER DECLARATION Name f � � 1 6,�G �
i hereby affirm that I am exempt from the Contractor's License Address ! c t.�x t
lpw for fha following reaso�(Section 703}.5, Business and • • c j v,�.;�, 7
�lPro iO�s Code): Cify Tel.No. �
,as.awner o4 the property,witl do ihe work and the u�,2 t-C�i�: �
strucrure is not intended or offered for sale (Setlion
7044,Business ond Professions Code).
1
CONSTRUCTION LENDING AGENCY �
I here6y afEirm fhat lhere if n cansiructiart lending agency for
the performance of the work for which this permit is issued
(Sec.3097,�v.C.}. - - _ -- �
Lender's Nnme .� . . .. .. - ... ,.�..... . - �- � . , . .. -
�
. . . .: . ._ . .. . . .
lander'a Address . �� - . -. _ .
. . _ ___ _ _.__. . __- .. .. . .. . . . .. .... ..... _.... . .._ ...._...._..... .----. ..---- ------�- - -
. .... ..... . . . . .......
1 te�ti4y fhot I hpve read this oppli[ation ond sfde eho�the . . . . . � � �� _ . .. , , . . , �
obove informafion is mrred.I ayree to comply with all Couniy _ . . �
ordinances and Slale laws regulating Plumbing,a�d hereby
puthorize representatives of this CouNy ro enter upon the �
ab e mentioned pr erty fo ' pection purpoaes. � - � � � _
�1` ��\„ •� ��_ .._ SEE BEVEASE#OB EXYLANATORY LANGLIAGE.m.__. _..__. .. , _,_ i
I��~Yr'�� -,_. ..._ . .._.. ' i
. ., .�. .. . . . .
.
Sig ur o ermiflee . Dale . , . . .. . . .. . . .., ...._ .._. _..-.,.,,_,......,. , .. __�... ,.. ,._.. .... t
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