HomeMy WebLinkAbout1649A (9) 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
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