HomeMy WebLinkAbout1722A WOR[CERS'COMYENSA'IION DECLARA7ION ]M867Y i
I hereby afPirm �hat � heye �rcertificate ��consept �ase�f �E.,�,s-.e, APPLICATION FOR PLUMBING -PERMIT {� �
insure,or a certiCicate of Workera'Compensation Insurance,or - ' . - �� I
u certified copy thereof(Sec.3800,La6.C•) �
COUNTY OF LOS ANGELES BUIlDtNG AND SAFETY
Policy No. Company , ��
� � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE1 OUILDING `���;l�� lr}�uNr „ 7/�� �
Certified copy is fited ' e o n y building inspection
NUMBER FIXTURE OR ITEM • FEE AO�RESS O� �/ /�' '��O t('
e arLF ent. WATER CLOSET �OCALIT �����J v?�-;
a � pplicant - � MEAREST � �
BATHTUO CROSSST.� � �
CERT[F[CA7E OF EXEMPTION rROM WO ERS' .
� COMPENSATION INSIIRANCE � SHOWER 6WNER • �,� �j��.r -
IAVATORY MAIL / r� /�� }
(This saciion need not be completed if tke work involvevl ADDRESS� ` U/�/V�`� (�' ,� a �
by the peimit is foc one hundced dollars ($1Q0)�c less� _ ,
SINK CIT '1 ,.�i� TEL.N05�� 7�� U
1 certify that in the perfotmance of the work for which this �ISHWASHER - �
perm#t is iss.ued,1 shal)not employ any pason in any mannei CONTRACTO / U..�J ���� Q �
so as to become subject to the Workers'Compensatiou Lxws. CLO7HE5 WASHER /<6. � - ,_^� f� r U
: Date Applicant DRESS��,J W �
. SWIMMING POOL RECEPTOR a ;
NOTICE TO APPLICANT:If,after making this Certiticate of CITY `� �{C�. TEL.NO3����� y
Exemption, you should become :ubject to the Workers' IAWN SPRINKLER Sv5FEM 5TATE �7 LIC. � �i
Compensation provisians of the Lahor Code,you must forth- yyqTER HEATER LICENSE NO.f G I 7�7 CLASS ��� i
with comply with such provisions or 4his permit shall be
deemed revoked. DISTRICT NO. PROCESSED BY
GAS SYSTEM OUTLETS
LICENSEDCQNTRACTORSDECLARATIQN OUTLETSOVER � lCl ,�4�f �
I hereby affirm that I am licensed under provisions of Chapter SVSF - �
9 (cnmmencing with Sec4ion 7000)of Division 3 of the 8usi- .� FINAL VALIDATION �
ness and Yrofessioris Code,and mY�icense is in full force and DATE 'L 2`�7L {
effect. tr...,� �
License Nurtbh• Lic.Classc,,� FINAL �
L ` BY �j(�1�2y �
Contract - Date ���'e_ o��
� [am exempt from the licensing requirements as I em a Plan check fee �
licensed archilect or a registereQ professionai engineer pLUM91NG PERMIT ISSUING FEE S
ac[ing in my professional capacity (Section 7051,Bus- :S1J �
irtess and Prnfessions Code). TpFAL FEE �j S� �
- Lic.or ReK.No. Date p�en check appficant
i
HO�tE OWNER-BUI6DER DECLARATtON Name � �-� � � - - � � - ��I-�-2 2 A---- �
I hereby affirm that I am exempt from the Contractor's Address�- � -� - � - � � � � �- -- � �� #� • • • •5 �
i
.l License Law for the following reason (Sec[ion_7031.5.Busl.- Cisy � � TeL No. � • •2 Q 5 C �
� ness and Protessions Cude): � •
;�� I,as owner of the property,nm exclusively rontra��ting � � � �� • •2 Q 5�� �
with licensed contractors to eonstruct the project
(SeMion 7044,Business and Yrofessions Code). . . . Q��3_$2 �
i
� CUNSTRUCTION LENDING AGENCY . � � � �
[ hereby sffirm thal there is a construc[ian lending agency
.for the performance of the work tor which this permit is �
issued(Sec.309'7,Ciy.C.).
Lender's Name E
f
Lender's Address �
I certify-that I have read t application and state that the �
above information is correct.7 gree to complY with all County SEE ltEVERSE FOR EXPLANATORY LANGUAGE �
ordinances • d S e laws re ulating Plumbing, and hereby
authorize re resenta ives af is County to enter upon the i
above-menti ned pr or inspection purposes �
/ I
U �- - � �
Signature of Permittee � Date j
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