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HomeMy WebLinkAbout1649A i.__ . . . . _ .. ...._. . . . .. . . r - . .._ ._. .. . _ . . .. _ .. . . . . _ . _ . WORKERS'COMPENSATIONDECLARATION � API"LI�rATION FQR rLUMBING�PL�MII� � � I;" I hereby offirm Ihot I have a ceriificate of consent to self 76A667A . � - � . . . insure,or a cer�ifimte of Workers'Compensafion Insurpnce, CE BV�REV,10/81) ' or a certified copy ihereof(Sec 3800,Lab.C.) COUNTV OP LOS ANGELES � BUILDING�AND SAPEYY .� ' P❑ol�icy No. Comppny � � CerTified copy is hereby fumished. BUILDING ❑ FOR APPLICANT TO FILL IN(PRINT OR TVPE) ADDRESS �� � � Certified copy is filed wi�h the county 6uilding insper .r—� tion depafiment. NUMBF.R FIXTURE OR ITEM (q) FEE LOCAIITV �'� �� . . WATER CLOSET si' tJ Dafe Applitant . NEAREST f � � CERTIFICATE OF EXEMPTIQN FROM WORKER$' BATH TUB CRO55 ST. rG, \ COMPENSATION WSURANCE owNER ,� �y� � ,5� �(This section need not be completed i(4he work involved by' SHowER �fhe� ermil is for one hundred Oollars 5100 or less. � MAII - P � � � WVA70R A�DRESS L`J i certify�hat in the performance of Ihe work for which ihis � � �permil is issued,i sholl noi employ ony person in any manner , SINK CiiY� `\ TEI.NO. ' � 'so as to become subject to ihe Workers'Compensation Laws.. �''��N � / , !^�1"f1 DISHWASHER CONTRACTOR � Date�.Applicant�^' "`^` WIYJ'1�\ CLOTHESWASHER ADDRESS � NOTICE TO APPUCANT: If, after making �his Certificate of _ — Exemption, you shauld become subject ro the Workers' SWIMMINGPOOLRECEPTOR Compensation provisions of the Labor Cade,yoo must forth- ��T� TEL.N0. wiiii cum I wiin sucn rovisions or inis �AWNSPRINKLERSYSTEM _ g p y p permit shall pe � STATE LIC. i deemed ievoked. . .. �. WATER HEATER LtCENSE NO. CLASS � IICENSED CONTRACTORS�ECLARATION DISTRICi NO. PROCESSED BY $ I hereby affirm ihai I am licensed undar provisions of Chapfer 9 � j GAS SVStEM � OUTLETS A �,� � � (commenting with Section 7000)of Division 3 of ihe Business ,�! OUiIETSOVER �� § and Professions Code,and my license is in fu.11 force and effett. f 5 PER SYSTEM S �.-. � VALIDATION .�., � FINAI DATE� I�} d' License Number Lic.Clpss � � � FINAI Contranor Date BY � � ❑ � I am exempt under Sec. O B.&P.C.for fhis reason '�'7 �4'v n � W Plan check fee � �u 0 a a �5 � Dofe: � PWMBING PERMIT ISSUING FEE$ ((� s'(% � � ¢ �� ��� , ;� Signat�re . . TOTAL FEE � O � ; .q ' /�\��,j� � Plan check appliccnt U y�� 4,._�� ' � SINGIE FAMILY � HOME OWNER-BUILDER DECLARATION Name I hereby affirm ihar I am exempt from the Contractor's License 4. � Law fn��hP f�ll�u,�„�.----,.�to�e�..,,7ngi 5 R��<�..e«v^,J A d dress Professions Code): City Tel.No. � �. I,as owner of the property,will do ihe work and the ' � siructure is nof infended or offered for sale ($ection , � 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY � I hereby nffirm�ha�ihere is a conslruc�ion lending agenty for ' ihe performance of the work for which this permit is issued (Sec.3097,Civ.C.). � Lender's Name —'`�' Lender's Address "f"7� � yt I ceriify ihoi I hove read this applim�ion nnd state Ihat the ! above informotion is correcr.I ayrr.e�o comply with all County ► . � ordinances ond 5tate lows regulating Plumbiny,and hereby outhorire represeNo�ives of this Co�nty to enter upon ihc � bove-mentioned property f�r insporlion p�rposes, � SEE REVERSE fOR EXPLANATORY LANGUAGE m - Signoture of Permittee Dare ��.-,�,�"'� �t°�!y z 1 C'�°�1 y`�'�,N`�y�, , �- tt". 7 ' 'r-+'- u''y4t���.�=ro�.,S��cD� . — o��� ':�'�, w qt�� z�� y�� . . ,- r � <��7!si� ;l - , . �� �r.�'a O�, ��,�`�i �. . 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