HomeMy WebLinkAbout1369A (218) �� WORKERS'COMPENSATION DECIARATION n � r� !��� � �: ' f�; �`'��-
I hereby,offirm�hat I have a cenifim�e of conseM�o self in- �-�Z6�PN'4i8� APPLICATION FOR PLUM�CIV..G��.PERMLT�sT;, .
76A667A
sure,or o cerlili[ote Of Wofkefs COmpenSolion InSu/on[e,or o 'CE 817(REV.B/86) - � � � � - � ' '`
cerf ified c9py,,��he�re�o�i(Sec.3800,Lab.C.) _ �'��'� �,
Policy No ��Company'�ll� �d1� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
� Certified copy is hereby iurnished. - eUnDiNG � I 1 �
FOR APGlIG1NT TO FILL IN�PRINT OR TVPE) ADDRESS p�DB3" I NF
Cer�itied copy is fiied with the coumy 6uilding inspet�ion
deparfinent. ' NUMBER FIXTURE OR ITEM @ FEE ��A�ITY
,rQ !7/ffilt rj
Do�e 1'�f" Applicant /�/� WATER CLOSET(TORET) NEAREST -
CERTIFICATE OF EXEMPTION FROM WORKERS' , BaTH TUB CRo55 57.
� COMPENSATION INSURANCE • , OwNER J�e� ��D
SNOWER
(This�Mion nNd not be complated il th�work inrolr�d by p,�qi� .
�hs pormil It for ona hundr�d dollnrs(SI00)or las�.) IAVATORY qDOR[55 �"/1'i�
1 certify thof in Ihe periormonce of the work for which this pei- SINK
mif i5 issued,I Shpll nol employ any person in any monner 50, CITY A�n�U`v A� TEL NO�'�/�/_�
�•r .si�
os to become su6ject to the Wakeri CompenSa�ion Laws. . DISHWASHER '
CONTRACTOR t �
Date App�itan� � CLOTHES WASNER AD�RESS � �� C KCSS
NOTICE TO APPLICANT:If,aNer moking ihi:Cenificare of Ex- SwiMMiNG POOL RECEPiOR
emption,yo�should become subject to the Workers'Compen- Ciiv �a y� / TEL.NO.%GG��S�I
w�ion provisions of the Lobor Code,you must forthwith comp- �,qWN St�RINKLER SvSTErn rf �
ly with wch provisions or this permit sholl be deemed re.vok- STA1E �f �i�' q S�
ed. • � WATER NEATER I LiCENSE NO. / C1A55 ��
LICENSED CONTRACTORS DECLARATION DiSTRICT NO. FrtOCF$�V '
I hereby a(firm Ihal I am licensed under provisions o1 Chopler GAS SYSTEM OUTlETS Q
9(commencing with Sedion 7000)of�ivis�on 3 0(�he Business OuilEiS OVER
S PER SYSTEM
and Pro(essions Code,ond my�icense is in full force and ef- FINAL �j VALIDATION a
fecL [ . / p � DATE /� � .
License Num6er���v�7 Lic.Class���7 V
t L� / FINA p�
CoNrocfor�` Date I'I[/� . , BY ,�T O
� ❑ r
I am erempt under Sec. U
W
6.8P.C.for this reason a
Plan check fee , z ;
DO1e� PIUMBING PERMIT ISSUING FEE S D �,1 3 6 9 A
Signature TOTAL FEE � � �'+ • �5
SINGIE FAMILY . -. p�an check applicanf -
HOME OWNER-BUILDER DECLARATION �I !I!� �5 O
I here6y aifirm ihof i om e.empt from�he Coniroctor's L�cense Name
Law for�he following reason(Sectian 7031.5, Business and �� • •� �j v�c=.o
Profesvons Code�: Address
� 1,os owner of the property,will do Ihe work and ihe City ' Tel.Na. ��.� 1� �8 9
strotlure is nol intended or oi(ered for sale�Section 7044,
Bus��ess and Prafessions Code�. �
CONSTRUCTION IEN�ING AGENCY ' - �
I hereby offirm that Ihere is a conslrvction lending ogency ior �-
the performance of the work ior whith this permil is issued _ .
(Sec.3097.Civ.C.). . , . . .. . . - . . .. . . . , .. . . . . . . ..
lender's Name � � '
I Lender's Address .
! I cartify Ihoi I hove reod Ihis application and stote iho�the � ,
iabove in{armolion is correcl.I agree 10 comply wi�h all County
I brdinances ond S�aie lows regulating Plumbing,and hereby
authorize representatives of this County fo enter upon ihe
I ,obov eNioned properry fo�inspedion purposes.
`` �/_g9 SEE REVERSE FOR EXPLANATORY LANGUAGE
Si alure of Perminee T Dale
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