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HomeMy WebLinkAbout1224A W'ORKERS'COMPENSATION DECLARATION �enan• I hereby affirm that I have e certificste of�o,�e„t to self �Ea,�,z-oo, APPLICATION FOR PLUMBING PERMIT {� insure,or a�certificate of Workers'Compensation Insurence,or �� � a certified cop the qP Sec.3800,Lab.CJ ; fll� (��.5�/�f�� ��� COUNTY OF LOS ANGEIES BUILDING AND SAFETY � Policy No. Company I � Certified co y is hereby furnished. ' P FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING j AODRESS �� �Q N�i� B G� j �Certlfied copy is fiied with the county building inspection NUMBER FIXTURE OR iTEM • FEE � �le arp trmen�i�A r�,"�._,/ �/, WATER CLOSET LOCALITY ��� z ! Date� pplicant y��� NEAREST 1 9ATH TUB CROSS ST. � C�G l/N � CERTIFICATE OF EXEMPTION EROM WORKEHS' � � I COMPENSATtON INSURANCE SHOWER OWNER � � MA1 L q �/>,`I {Th13 SEChOR IIC¢d rtOt bE COIpQl¢tCd IF t1lC WOtk {IIVOIvCI� LAVATORY qDDRESS oC�-77�J � �'�11,1� � d ! by the permit is foc one hundred ollars($100)or lesa.) O � � SINK CITY Q. r� . T L.N ��l�� U � 1 eertify that in the per rmance f the work for which this DISHWASHER K permit is issued,I shall no emp y any person in any manner CONTRACTOR _ so as t�o b'e7c�om�e subject to he o e€s'Compertsatiun Laws. CLOTHES WASHER �/y� � � O � Date ��!v Z.Spplicant W � ADDRESS a s �'6/N�t� w � SWIMMING POOL HECEPTOR � NpTIC�TO APPL[CANT: f, fter making this Certiflcate of � CITY �N�� � T t�//�/l�' g � Exemption, yvu sho¢fd eco e suhject to the Workers' LAWNSPRINKLERSVSTEM S7A7E �.,.r!� LiC. � Cumpensation provisiuns of the bor Code,you must forth- �qTER HEA7ER UCENSE NO. ��lf� CLASS �—S� � with comply with sue provisions or this permit shall be deemed revoked. GAS SYS7EM OUT�ETS 6 �ISTRICT NO. PH ESSE�8Y E CICENSED CONTRACTORS DECLARATION OUTLETS OVER f� L,ca-C� � F herehy afPirm thnt 3 am licensed under provisions of Chapter 5 PE R SYSTEM � j. 9 (cammencing wi[d Seclion 7000)of Dirision 3 of the Busi- FINAI � ness and Professions Code,and my license is in full force and L-� n �l Q DATE �����2 VALfDATtON f effect. �- License Numbor �� L'ec.Class �^ �J FINAL �. � p '-7 BY ' Contra�tor,l•L �ie_TLl�✓F'.r Date /' /'8� � `; � 1 am exempt £rom the licensing reyu'vements as I am a Plan cheCk f¢e � ticensed architeM or a �egistered prufessiortal engineer pWMBING PERMIT ISSUING FEE$ 1 � , ac!ing in my professional eapacity (Section 705t, Bus- _ ii(ess und 1'rofessions Code). TOTAL FEE .s v Lic,or Reg.No. Date Plan check applicant � { HOME OWNER-HU[LDER DECLARATION Name , aee.� �1 2 2 4 A � I here6y affirm that I am exempt Pwm the Contractor's l .License Law for the following reason (Section 7031.5, Busi- Citv Tel.No. #• • � � �5 � ness and Yrofessions Code): � � � I,as owner of the property,am exelueive(y contracting � • • � (a 5 Q � with licensed contractors to construct the project � (Sectiun 7044,Business and Professions Code). - • • • � �5 C V � � CONSTRUCTION LENDING AGENCY � O L O 7`H Z � I hereby afflrm that there is a cunstruction lending agency for the perfurmance of the work for which this permit is � 3 issued(Sec.3097,Civ.C.). 1 Lender's Name i Lender's Address �� � I certify that I have read this application and state thul the � above information is correct.I agree to emnply with all County SEE REVERSE POR EXPLANATORY LANGUAGE mdinunces and State laws regulating Ylumbing, and hereby authorize representatives of this County to enter upon the � abovn-mentioned property For inspection purposes. j �,Q/���,G+.�� �'��`Ba' � ig5 nature of Permittee Date I y ; � � �; �. ��� ��, .;, ,=s ., " . 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