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HomeMy WebLinkAbout1775AWORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C. C Policy No. (© ompany S ri Certified copy is hereby furnished. Certified copy is filed with the county building inspection de ar m jn_t._ Date_l v- Applicants%Z CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This section need not be completed if the work involved by the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this Permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: if, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code. and my license is in full force and effect. License Number 7r*AJ Lie. Class 431 r ContractoF//%% '7 Date ! 0 1 am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Bus- iness and Professions Code). Lie. or Reg. No. Date HOME OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, BaSi- ness and Professions Code): 13 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and St a laws regulating Plumbing, and hereby authorize repres tives of this County to enter upon the above- entio property for inspection purpo ps.FZ Y ! to Signattlr f Permittee Dae / ceav(r-ao) APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING /.,/ f` AODRESS f f'{O T V, NUMBER FIXTURE OR ITEM • FEE WATER CLOSET 1 hni 1t1 LOCALITY BATH TUB NEAREST —/ CROSSST. [ SHOWER Q OWNER LAVATORY a MAIL .pADDRESS SINK CITY TE f71Or DISHWASHER CONTRACTOR A CLOTHES WASHER ADDRESS 6) SWIMMING POOL RECEPTOR CITY TEL. (f/— ,7/77LAWNSPRINKLERSYSTEMSTATE ,VS 2_0LICENSENO. ciJ LIC. .Fgj CLASS f] WATER HEATER GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY D UTLETS OVOVER 5 PER SYSTEM FINAL DATE /0/,/ V/F 3 FINAL BY %Ut_ VALIDATION 7 7.5 A G Plan check fee PLUMBING PERMIT ISSUING FEE $ b TOTAL FEE Plan check applicant Name Address City Tel. No. SEE REVERSE FOR EXPLANATORY LANGUAGE r • *24,50 24.5050 Q3C8-82 G OU Cr 0 W N Z G c, a :I.. z -V fi 1z -t! 14; Z: C Its t 4 t C, WJ zz z, E; :27z Z. z tL 17 n Z tr U) 4. LL en Lu LU LU LL j i mlJCL0 0 J! LL cCCIa. m uj F-! ina- ui zio b Z