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HomeMy WebLinkAbout1369AWORKERS' COMPENSATION DECLARATION I hereby, affirm that I have a certificate of consent to self in- sure, or a certificate of Workers' Compensation Insurance, or a certified c9�py Iln eof (Sec. 3800, Lob, C.) Policy No 1Ld- Company --rtl/ef tUa Certified copy is hereby furnished. - Cewiled copy is filed with the county building inspection department. Dote :`L—*N Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed it the work involved by the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so, as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, offer making this. Certificate of Ex- emption, you should become subject to the Workers' Compen- sation provisions of the Labor Code, you must forthwith comp- ly with such provisions or this permit shall be deemed revok- ed. LICENSED CONTRACTORS DECLARATION I hereby affirm Thal I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and ef- fect. License Number - Lice Class 7� UG—S Contractor ( 6 Date I am exempt under Sec. B.BP.C. for this reason Date: Signature SINGLE FAMILY HOME OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Controctor'$ License Low for the following reason (Section 7031.5, Business and Professions Code): F1 1, as owner of the property, will do the work and the structureis not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). .. Lender's Name Lender's Address I certify that I have read this application and state thal the above information is correct. I agree to comply with all County ordinances and State lows regulating Plumbing, and hereby authorize representotives of this County to enter upon the abov gnentloned property for inspection purposes. SG4-89 ii"clFature of Permittee Date T\ 20-0016 DPW e/87 APPLICATION FOR PLURMLT sf; LI 76A667A CE 817 (REV. 9/86) - --�' COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS FOR APPLICANT TO FILL IN (PRINT OR TYPE) NUMBER FIXTURE OR ITEM @ FEE WATER CLOSET (TOILET) BATH TUB SHOWER LAVATORY SINK DISHWASHER CLOTHES WASHER SWIMMING POOL RECEPTOR LAWN SPRINKLER SYSTEM WATER HEATER GAS SYSTEM OUTLETS Plan check fee PLUMBING PERMIT ISSUING FEE $ TOTAL FEE Plan check applicant Nome Address City Tel. No. SEE REVERSE FOR EXPLANATORY LANGUAGE AD RESS p(Li(J3�J MBGc.L/I�1F LOCALITY bil qw „ > rTT KT 2iJ� NEAREST _ CROSS ST. OWNERJFe4,! MAIL � 7 ADDRESS �rT rrL� CITY A�t'rft,Vp 0,4k TEL. NOSI'f / CONTRACTORl�✓ ADDRESSNQYfn�C slsi= CITY /Tay7Y TEL. NO.%GG/CTEL. NO.%GG—/ STATE ��// LICENSE NO�^ / UC. //tt CLASS T� �/ CLASS F� S� DISTRICT NO. PROCE$SF.Q9Y DATE pC� VALIDATION 21369A q..:..5 1 •.11 650 vi 16500 041111_-89 T O !w0 T C � W O O D L T C G7 9 O O D C Dp Z H r C C N C r (n i O my m u m =' m mm D 9a p O m 'n z t; v rr' A O O A O O Sc 2 m O > c n z o Irl a � O N ` J 4 1 n m rn m 0 ^- z v M Cf H A y Ln O Z D c D m Z v m 0 4 O z O m to — ooac�a�o�ni0� e�� "Z y d omv - ,mtimac�, ='�naa^oil ii SO. 0, ` C.:,i CD co r� 'c rn O r- am2:�g` X03©%�'©�?3�^�0 0 �$Cb do?xw�amc^coo: l7 m0, ori`=a" 3mamo o0�� m „on,mma0ZM o(��oQ o�03 Z,�a �� �¢+4 e% BOOv' O'm(D mO �1O"3 H O f� m— O f Q m W tr nuc C, C, m O C�yfm y -oma o m"o�tob"mo�o O �maC" Z'Cb �. Z CD cl sx n Cat0 am 51xrc �o' a=am449C�n. �- m