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HomeMy WebLinkAbout0161AWORKERS' COMPENSATION DECLARATION zeweszA I hereby affirm that I have a' certificate of consept to self cE 817 (z-ao) APPLICATION FOR PLUMBING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copyy thereof e(gSec.,g3800, Lab. CC./)) oLi } m t� � C` ( I Gf cy No. ompany 9s Fyz2.LL-YX �J7�� G' ertified copy is hereby furnished. Certified copy is filed with the county building inspection N e�a tn3e�. / / r Date-:; Applicant / <!✓ 1r'S` /JPI ter[ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section 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, 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, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect. L' ens/e� Num�b,�er —Tr KLic. Class,F� D,/t 7 ,. Contractor 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- iness and Professions Code). Lic. or Reg. No. Date HOME OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.S, Busi- ness and Professions Code): I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (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 that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above- ntioned property for inspection purposes. COUNTY OF LOS ANGELES FOR APPLICANT TO FILL IN (PRINT OR TYPE) UMBER FIXTURE OR ITEM FEE WATER CLOSET BATH TUB SHOWER LAVATORY SINK DISHWASHER CLOTHES WASHER SWIMMING POOL RECEPTOR LAWN SPRINKLER SYSTEM WATER HEATER GAS SYSTEM OUTLETS OUTLETS OVER 5 PER SYSTEM 0 iiM Plan check fee PLUMBING PERMIT ISSUING FEE $ TOTAL FEE Plan check applicant Name Address City Tel. No. SEE REVERSE FOR EXPLANATORY LANGUAGE BUILDING AND SAFETY ?f 3'2 a 7 - f'.. O'er BUILDING jV e,,e 9 _ ADDRESS LOCALITY"��'����� NEAREST CROSS ST. OWNER ADDRESS CITY TEL. NO, CONTRACTOR I _l ADDRESS;�'G-; / '2 CITY ,� TEL. NO.`l STATE LIC. LICENSE NO.� CLASS DISTRICT NO. 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