HomeMy WebLinkAbout1141A (5) ,
WORKERS'COMPENSATiONDICLARATION � JBA669A
� he«bY �tr��m �aa� � ��av� a�e«,r;�ate of consent to se�F �E.,�,�Z-eo, APPLICATION FOR PLU,.M,B ING PERM IT �r.
'`�Iinsure,or a certificate of Wbrkers'Compensation Insurance,or . .
n certified copy thereof(Sec.3800,Lab.rCf.r)�('`LL COUNTY OF LOS ANGE LES BUI LDtNG AND SAFETY
.Policy N6(LL—w'QL�sCbmpany ��•�`YI 1 [i _ , . .
� � Cet[ifieti copy is hereby furnished. FOft APPIICANT TO FILL IN(PFiINT OR TYPE) BUILDING �1
� Certified co UMBER FIXTURE OR ITEM � FEE ADDRESS O( IO I ,
� py is filed�vith the c unty building' spect�on .
� ��—��Q(�t� WATER CLOSET LOCALI7V
Uate��APPlicant NEAREST
BATH TUB CROSS ST. ��
CERT[FICATE Ok��:XEM1SPTSON RROM WORKER5'
COMP1iNSATIUN INSURANCE SHOWER OWNER
LAVATORY MAIL ��
(This section need not be completed if[he woik imolved qoortess�, _ , �'
by the permit is fur one hundred dotlars (5100)or lcss.) SINK Y
� CITV qVpS�� C7 ,
I certify that in the performance of tha wurk fw which this -- U �.
DISHWASHER CONTRACTOR�x
permlt is issued,I shaU not employ any person in uny mannec _
�.i
so na[o hecume subject to the Workers'Compensation Laws. C�OTHES WASHER ADDRESS �' '�
Date App�icant SWIMMING POOL RECEPTOR � 'C�
NOTICE TO APNLICANT:If,after making[his Cettificate of - CITY T • 8•� r a �
Exemption, you shouid become sub�ect t� tbe W�rkers' LAWNSPRINKLERSVSTEM
Compensation pravisione'of the Lubor Code,you must forth- STATE LIC. /7�/ /��j r�
ivith comply with such prqvisions or ti�is 9ermii shall 6e WaTER HEATEF LICENSE N . O CLAS'u'�� QL+„]
deemed rev�keJ. GAS SVSTEM OUTLETS OIS7RICT NO. PROGESSED BY
`I.ICh:NSi;ll CUNTRACTORS U1:CLARATION OUTLETS OVER J�t-a ` .�-�,�+r .
I hereby nffirm that f am licensed under provisions of Chapter S PER SYSTEM — � --
9 (commencing wiih Section 7000)u£Division 3 of the Busi- ,? FINAL .
ness and Professi�>ns Code,and my iice.nse is i��fWl force und �GQ. ��� �AT�� ��� VALIDATION
effect. �1
License Numl>eY`��� Lic.Clase� ��+`�� FINAL �
@ BY
Contractor�J� Date����
� Plan check fee �
I am exempt from the licensing requirements as I am a
]icensed architect or a registered professional engineer pLUMBING PERMIT ISSUING FEE$ '� � �
acting in my professional cxpacity (Sectinn 7051, Bus- � .
iness und Professions Code). TOTA4 PEE S� '�1 1 G,1 A � ;
Lie.or Reg.No. Date _ Plan check app�ir,ant � � n m c
��° v
HOMF.OAVNER-BUILDER DF.CI.ARA]'ION Name �
— — — 1 ! G 7 Q
- 1 hereby affirm [hat I am exemp[ f'rom the Contractor's Atldress — • � y y
Licanse Law for the folluwin reason Section.7031.5,Rusi- � � Z' �� �
S �• CitV Tel.No.
ncss and Nrofessions Code): , �2�g�,�� „
�. � I,as owner uf the property,am ezclusively contracting . ,
with licensed conhactors to construc[ the project .
(Sectiun 7044,Businees and Vrr>fexsions Code).
CONSTRUC9'iUN ld!NDING AGLNCY
1 hereby afTirm thn[ there is a conctruc[ion lending agency �
for the perfor�nance of the work for which [his Permit is - -
' issued(Sec.309'1,Civ.CJ.
Lcnder's Name ,
Lender's Address
I certiTy[hat I hnve mad this application and state that the
above information is rnrrect.1 agre o comply with all Cowuy SI+.R REV ERSH'FOIi CXPLANATORY LANGUACE
o dinunces and Statc laws regulaf Plumbing, and hereby �.
a orize represenh bes of this nty to ter upnn the
o c-mcntioned r �rty � � spe n ses.
�a aa-g�
nature of Pennittee D e
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