HomeMy WebLinkAbout1158A (5) WORKERS'COMPENSATION DECLARATION I
APPLICATIO{V �OR PLUMgIR�G PE�tT ���777
I hereby affirm thof i hcve a certificate vf consenf ro self 20-OD26 DPW 6/87 G,� I
i�sure,or a certifitote of Wwkeri Compensalion Ins�rance, 76Afi87A - I I �
or o certified copy thereof�Sec.3800,�ab.C.) COUNFY OF LOS ANGELES DEPT.OF PUBLIC WORKS U
P❑olity No. Company
Certified copy is heraby furnished. f
OFOR AP7LICANT TO FILL IN PRINT OR TYPE g�����'
Cerfified copy is filed with the counry building inspeo- ( � A�DRESS � 3 3 �+�'� �S`�G��+V�
tiondepariment. NUMBER FtXTUREORITFM � FEE ���'�, . � ��, ��� ✓ �
WATER CLOSET
Date Appfi4Ont NEAREST �
CERTIFICATE OF EXEMPF�ON FROM WORKERS'
BATH TU8 eRoss sr. �—t.YY�p- �
COMPENSATIpN INSURANCE OWNER /� A [
(Thi�wction nwd no►Fw compbt�d if 1h�work imolrw!by SHowER ( '�D t 4� �(f��L�i C S t� � �
tb�pormk�s(or o�w hundrod dollan(SI00)ar Irss.) �qyqTagy M'°'�� c �
A��RFSS l' �.
I certify that in the pe�fo�monce of the work for which this t
permif is issued,1 shafl nof employ any person in any manner SINK f�TY .�_ hY� TEL. -�� ��3 �
w aa ro bacome w6ject to tht Workers'Compansotion Laws. DISHWASHER
CONTRACTOR �
a�� � .�� 4 1°l��� ,��� �
Date pplitant��,��ti�'� CIOTHES WASHER ADDRESS
NOTI O PPIICAkT: If, offer making thia Certificate of C u
Exemp4ion, you 4hould become subjeU to the Workers' SWunMING POOI RECEVTOR ` > �
Compenaclian provision�of ihe lobo�Code,you myst fonh- IqWNSPRINKtERSYSTEM C'TY �� � t2 �` #
with comply wifh euch provisions or fhie pe.mit aha�I be STaTE LIC.
deemed�evoked. WATER HEATER
tICENSE NO. ` �� �- ` �b I
LICENSED CONTRACTORS DECLARATION D�STRIC/NO. ` 55ED BY
1 hereby affirm that I am Ilceroed undm provislans of Chapter 9 GAS SYSTEM EHl7LET5 ;
(commencfng with Sec�ion 7000)of Divi�ion 3 of�he Buaineas OUTtEi50veR
rit`G.-�'t'!�' z
and Pr��ssions Cods,and m liceme is in full fores and effect. S PER SYST r- 3= "
yy�'�7 �_� � � oaTE t0 ��� � S VALIDATION U ±
Uwnw Number �ic Claaa
�` �/' FINAI � �
Contractor ���- /�l�'��Octe � �' �' BY �1--
❑ f om sx�mpt und�r S�c. V i
a ;
B.BP.C.for�hl�reason_ S�.. p�on check 4ee �� � 5 8(1 . Z ,
Da�e: �'
� �� PIUMBING PERMIT ISSUING fEE$ � #r•• • �5 '
$i�noture �
FOTAL FEE I+�:I 6 5 Q �
Plan check opplicanf • • •� Q 5 n'W '
S�NGLE FAMILY
HOME OWNER-BUILDER DECWRATION Nome Q���—8 9 �
1 hareby affirm that 1 am exemp�from the Contrecror's L�cense qddress � �
' law for the following reason�Seclion 7031.5, Business and �
Professians CodeJ: City Tel.No.
❑ 1,os ownat of the p�operty,will do the work and the �
structure is not intended or offered for sale(Section �
7044,Business and Professions Code). #
CONSTRUCTION LEND�NG AGENCY �
I hereby offirm thnt Ihere is a construdion lending ogenty for �
the performpnce of the wark for which this permir is issved j
(Sec 3097,Civ.C.).
�
tender's Name -
Lender's Address '
I tertify that 1 have reod this opplica�ion ond stala ihat the � �
above information is conect.I agree to comply with all County
ordinonces end Slote laws regulating Plumbi�g,ond here6y �
_ authorize representatives of this CooNy �o enier upon ihe �
above-menlioned property for insp tion purposes. �
__�� �/�/�� � SEE REVERSE FOk EXPLANATORY LAMGUAGE ?
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