HomeMy WebLinkAbout0805A (4) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
I heteby,offirm Ihat I have a certlfico�e of consent io self in- p���6 DPW aiB7 �
sure,or o certiiica�e of Worken'Com ensolion Inwrance,ar a 76A66�A
P CE 817(REV.eie6) .
cerlified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES EPT.OF PUBLIC WORK$
Policy tvo.73WC00504Z.QiQ�hyNATIONWIDE�_ �
� Cerfi(ied copy is hareby furnished. � Bua�iN� '
FOR APPLICAM TO FIIL IN(CRINT OR TYPE)
� Certified copy is filed with the county building inspectian n�DRE55
depar�menl. ; NUMBFR FIXTURE 041TEM Ci FEE �«A�ITY
Da�e 9-1-88 AppGco��NEW PLUMB�G N'ATER ClOSET(iOqET) 1$ NEAREST
� CERTIFICATE OP EXEMPTION FROM WORKERS' � 2 BATti TUB 1 z CROSS ST. '
COMPENSATION INSURANCE � SHOWER OWNER � �
(Thif�aNion n�ed noi b�eompleted if tha work Iarolved by MA��
Ih�p�rmll i�for ona hundrsd dallan(3100)er I�ss.) LAVATORY AD�RESS ,
, I certify that in fhe periormance oi the work for which this per- SiNK
mil is iss�ed,I sholl not employ any person in ony manner so . CITY A �A TEL.NO. _
as fo bamme subjecf 10 the Warkers Compensalion laws. Di5HWA5HER
CONTRAC70 � �,�„�
�ole AppliConl � i CIOTHES WASHER 6 ADORESS
NOTICE TO APPLICANT:li,olfer moking Ihis Certificote oi Ez- SWIMMING POOI RECEPTOR
emplion,you sho�ld beCome su6jecl to the Workers'Compem CITY TEt.NO.
solion provisions of the Labor Code,you must fo�thwith mmp- � �pWN SPRINK�ER SVSTEM �
ly wi�h such prov�slons or this permit shall be deemed revok- Siaie uC.
ed. WpTER HEATFR LiCENSE NO. fiASS �
LICENSED CONTRACTORS DECIARATION . DiSTRiCT NO. PROCESSEU Br
I hereby affirm thol I om licensed under provisions of Chopler GAS SvSTEM OUTtEiS /v
9(commenc�ng with Section 7000)of Division 3 af ihe Business Oui�EtS ov[R
1ed Profestions Code,ond my license is in(ull force ond ef- 1 5 PER SYSiEM 1 5� FINAL .z� V LIDATION a
426109 oATE l �
L�cense Number Lia Class C-36 �
FINAL V
Coni�octo� NEW PLUMBING Date 8-31—$8 BY � O
t-
� I am eKemp�unde�Sec � W
. B.SP.C.tor this reoson ► vai
Plan check fee Z
Date: p�UMBING PERMIT ISSUING FEE 5 :'O S O::PI
� Signalu�e � TOTAL FEE � • e • c •� '
SINGLE FAMILY �
HOME OWNER-BUILDER DECIARATION 71on check oppliconl
I heraby a(fi�m tha�I am eaempi from ihr,Con�roUor i license Noma , • , t �C n
law for the(ollowing rcason�Section 7031.5, Business ond . e � � � ��r,�
profess�ons Code): Address '�' �
� Cit Tel.No. O a� � —`��
I,as owner oi�he proper�y,will do the work ond�he Y
struclure is not intended or olfered for sa�e(Seclion 7044, .
Business and Professions CodeJ. �
CONSTRUCTION LEN�ING AGENCY � , '.
I hereby affirm�hol there is o construclion lending ogency for �
ihe performonce of the work for which this permit is issued ' ' �
(Sec.3097,Civ.C.�. �
lender's Nome
Lender's Address
I certify�ha�I have read this applimiion ond sto�e�ho�ihe � .
obova infoimotion is corretf.I ogree�o camply with all County .
ordinonces and Slate law9�egulofing Plumbing,and hereby � � �
ou�horite representa�ives of this Coun�y to enrer upon the
�V�o e•m �ioned property far inspec�io purpose ' �
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signoture of Permittee Dote �
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