HomeMy WebLinkAbout6072AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a' certificate of consent to self
rcwswA
ce sn (z-ao) A P P.,,I C AT I O. N FOR. PLUMBING PER M ITinsure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOSANGELES BUILD,ING-AND.SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING''S y(' • w_
2fooADDRESS
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
department. LOCALITY
Date Applicant WATER CLOSE T
BATHTUB i
NEAREST
CROSSST.,'T,L-f//+/A C._..":
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
This section need not be completed if the work involved LAVATORY MAIL
by the permit is fox one hundred dollars ($100) or less.) ADDRESSG
SINK CITY yITEL. t&4(1-0'744certifythatintheperformanceoftheworkforwhichthisDISHWASHER
T
M." permit is issued, I shall not employ any person in any manner
orl^'Ca
CONTRACTOR
so as to becomes subject to the,kl'orkers' C ompens^` ah_ , CLOTHES WASHER
L.I3L',"IOYJ-/K. l•./\ Dates Applicant_
ADDRESS U
NOTICE TO APPLICANT: If, after making this Certificate of
SWIMMING POOL RECEPTOR
CITY ] TEL { v5 U)
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM
Compensation proyisions of [be Labor Code, you must forth- STATE ^-
cxwithcomplywithsuchprovisionsorthispermitshallbeWATERHEATERLICENSENv3L
deemed revoked.
GAS ( M J OUTLETS
DISTRICT NO. PROCESSED BY
LICENSED CONTRACTORS DECLARATION ETSYSTEOVOUTLS ER IIherebyaffirm.,that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL
tress and Professions Code, and my license is in full force andDATE= p'j VALIDATION
effect. 1 i i l
y' gLicenseNuubeP` •!3_0 CR —C_ FINAL
Ic. 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.FEEactinginmyprofessionalcapacity (Section 7051, Bus-
iness and Professions Code).
TOTAL FEE 6 . r:r i w ®dJ. pj
Lie. or Reg. No. Date Plan check applicant q
HOME OWNER -BUILDER DECLARATION Na me
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section 7031.5, Busi- City No. Tel
tress and Professions Code)a..:,.,.,.k.,•.,<,-.., .-.w...,.n.. „,...-,.. ..>« W ,-, ,.. ,._,..
1, as owner of the property, am. exclusively contracting
with.. licensed, contractors to construct the project
Section 7044, Business and Professions Code).
CONSTRUCTION. LE NDJNG AGENCY
I hereby affiUt; that, -there u,.a construction lending agency
for the PAFformanCE,.of .the work for which this permit is
sued (Sec. 3097, Civ. C.)ip-G=\.(,, ..
Lender's Name
I certify that 1. have read this application and. state that the
above. information is correct. I agree to comply with all County
ordinances and .State laws regulating Plumbing, and hereby Y_FR§.E,,,FQR EXPLANATORY LANGUAGE
authorize representatives .Of thisCountyto, enter upon the
above-mentioned property for insp.cttQ,n purposes.
Sisnarure of Permute a Date
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