HomeMy WebLinkAbout1379AWORKERS'COMPENSATION DECLARATION
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APPLICATION FOR
PLUMBING PERMIT
1 hereby affirm that I have a' certificate of consent to self
CE $17(2-.a)
Insure, or a certificate of Workers' Compensation Insurance, or
a cerci ped c py thereof (Sec. 3800, Lab. C.)
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f+riiCOUNTY OF LOS AELES
BUILDING AND SAFETY
Policy No.Company e�L
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Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
BUILDING J
ADDRESSSCrKSi. (TRIC G7 S ILIA/
Certified copy is filed with t e c Linty buil Ing inspection
NUMBER FIXTURE OR ITEM • FEE
LOCALITY
�1ep r e
WATER CLOSET
Dateppl(c
NEAREST
BATH TUB
CROSS ST.
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CERTIFICATE OF XE ION FROM WORKERS'
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COMPEN AT NINSURANCE
SHOWER
OWNER {7'r�/J", Sri.,,/C.`; [!' 6
(This section need not be completed if the work involved
LAVATORY
MAIL
ADDRESS
by the permit is for one hundred dollars ($100) or less.)
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SINK
CITY TEL. NO.
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1 certify that in the performance of the work for which this
is issued, 1 in
DISHWASHER
CONTRACTOR 1
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permit shall not employ any person any manner
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so as to become subject to the Workers' Compensation Laws.
CLOTHES WASHER
ADDRESS s',r2Fes�
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Date Applicant
/
/ SWIMMING POOL RECEPTOR (!
NOTICE TO APPLICANT: If, after making this Certificate of
CITY TEL. NCQ0 `/S1,8
IGC IJc ►n
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
STATE / G�'i LIC. c
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with comply with such provisions or this permit shall be
WATER HEATER
LICENSE NO. 6 W CLASS
deemed revoked.
/ GAS SYSTEM OUTLETS 1 G�
DISTRICT NO.
PRO SSED BY
LICENSED CONTRACTORS DECLARATION
OUTLETS OVER
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I hereby affirm that I am licensed under provisions of Chapter
9 Section
5 PW SYSTEMv
FINAL
(commencing with 7000) of Division 3 of the Busi-
11"s and Professions Code, and my license is in full force and
/iL
DATE ��
VALIDATION
effect.
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FINA
License Numb Lie. Class
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By
BY
I am exempt from the licensing requirements as I am a
Plan check fee
licensed architect or a registered professional engineer
PLUMBING PERMIT ISSUING FEE S
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
TOTAL FEE l�
Lic. or Reg. No. Date
Plan cheek applicant
HOME. OWNER-BUILDER DECLARATION
Name
I hereby affirm that I am exempt from the Contractor's
Address
License Law for the following reason (Section 7031.5, Busi-
City Tel. No,
I:E1 3 7.9 A
ness and Professions Code):
❑ 1, as owner of the property, am exclusively contracting
# . . • s . 5
with licensedcontractors to construct the project
(Section 7044, Business and Professions Code).
-20.50
CONSTRUCTION LENDING AGENCY
-
• e• 2 0.5 O 5
I hereby affirm that there is a construction lending agency
for the performance of the Work for which this permit is
0 1.29-82
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
SEE REVERSE FOR EXPLANATORY LANGUAGE
'
ord' ores and State laws regulating Plumbing, and hereby
ithon of this County to enter upon the
Msentstives
a tuned pro rty for inspection purposes.
r� (may
`above-
at ure of Permittee Date