HomeMy WebLinkAbout1847AWORKERS'COMPENSATiON DECLARATION .j
I hereby affirm that l have a certificate. of consent tn'self
insure, or a certificate of Workers' Compensation Insurance, or
a certified appy thereof (Sec. 3800, Lab., Q.)
Policy No. '`'Company={'�"`r�:.^r
Certified copy Is hereby furnished. ry'r /
�} f � / � ��{
Certified nopy is filed with the cgvl�y}�rdingAn�speition
x;. C p ff 111jjjfff(((
I Date.1 t.' Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
-(This sexedon need not be completed if the work involved
by the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
I. Exem ber the
ytion, you -should become su,,ict , to W. orkers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
!7 'I hereby affirm that I am licensed under provisions of Chapter
L 9 (commencing with Section 7000) of Division 3 of the Busi- a.
�+ ness and Professions Code, and my license Is in full force and
effect.
+ License Numbet-•~"j-'1+ Lie. Classy' 3
df?'S'l'y
I,Contractor f,� i r' �' o Date
'El I am exempt from the licensing requirements as I am a €
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-.
111 iness anti Professions Code).
I
rLic, or Reg. No. Date '
HOME OWNER -BUILDER DECLARATION
{ 1 hereby affirm -hat I am exempt from the Contractor's �r
License Law for the following reason (Section 7031.5, Rusi-�
ness and Professions Code): ,
1, as owner of the property, am exclusively contracting
with licensedcontractors to construct the project
(Section 7044, Business and Professions Code). '•
CONSTRUCTION LENDING AGENCY g
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
I, 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
ordinances and Sa laws,re lating Plumbing, and hereby
authorize rnpprppffse atige{,�oi,t s County to enter upon the
above -m 5#fed ro�yea•Yy fo spection purposes.
pi w
Signature o ermittee Daie
cE e;r(a-so, APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGE LES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
:R FIXTURE OR ITEM 0 FI
WATER CLOSET
BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
GASSYSTEM OUTLETS '.
OUTLETS OVER ,
5 PER SYSTEM
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name
Address
City Tel- No.
SEE REVERSE FOR HXPLANATORY LANGUAGE
BUILDING ,q t
ADDRESS
LOCALITY J
NEAREST
CROSS ST.
OWNER
MAIL
ADDRESS
CITY
CONTRACTOR'%':;', _y
ADDRESS
CITY
STATE t.7 r" i
LICENSE No.
DISTRICT NO.
1
FINAL
DATE
FINAL
BY
'TE LyNO,_:
_i
}"
Ci.
TEL. NO
LIC. ,r ;;^':
CLASS' ,:,,A. :Fi
�;•
PROCESSED BY
VALIDATION