HomeMy Public PortalAbout9068 ACASO DR_Plumbing_9/21/1981 WORKERS'COMPENSATION DECLARATION A l APPLICATION FOR PLUMBING PERMIT
hereby affirm that I have a certificate of consent to self �CE cE 81 ei7(z-ao -
nsure,or a certificate of Workers'Compensation Insurance,or '
1 "fl
certified copy thereof(Sec 3800,L b Y COUNTY OF LOS ANGELES BUILDING AND SAFETY
olicy No Company �� ' 01 Cj . P
Certified py is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILD G �/ (� ' ��`
15aq it d ounty buil rnspection
NUMBER FIXTURE OR ITEM • FEE ADDRESS �-�'06 9: � C S0 /i-iG/l.�
C1Y+ t LOCALITY
WATER CLOSET
ate - Applican NEAREST
° BATH TUB CROSS ST
•CERTIFICATE OF EXEMPTION FROM WORKERS' n
COMPENSATION INSURANCE SHOWER OWNER JAA.r
LAVATORYr, MAIL '
his section need not be completed if the work involved ADDRESS }
y the permit is for one hundred dollars ($100) or less) SINK + J CITYTEL NO
0
lcertify that in the performance of the work for which this DISHWASHER 3 "U•
ermit is issued, I shall not employ any person in any manner CONTRACTOR
as to become,sublect to the Workers'Compensation Laws CLOTHES WASHER
l ADDRESS 109 eo 9-0 �
late Applicant SWIMMING POOL RECEPTORU
OTICE TO APPLICANT If, after-making tfiis Certificate of f CITY TEL NOL/g2'�O'7 9LU
L
xemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE //►q
ompensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO I� f 5 CLASS �7oG 12 z
ith comply with such provisions or this permit shall be
emed revoked GAS SYSTEM OUTLETS DISjTR,1CT NO P CESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER Q� r
ey affirm that I am licensed under provisions of Chapter 5 PER SYSTEM(comrebmencing with Section 7000)of Division 3 of the Busi- DATE �"' ��— Q VALIDATION
ss and Professions Code, andFINAL
my license is in full force and
tCID
fect
tcens m er tc Class FINAL
BY
on r J Aah�te
I am exempt from the licensing r uirements as I am a Plan check fee -
licensed architect or a registered professional engineer S ref\
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code) TOTAL FEE
c'or Reg No Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name t m
hereby affirm that I am exempt from the Contractor's' Address ^
icense Law for the following reason (Section 7031 5, Bust- City Tel No -
�ess and Professions Code) J I
1, as owner of the property, am exclusively contracting 9 0 9 7.9-A
with licensed contractors to construct the , project ,
(Section 7044,Business and Professions Code) i -- # ° ° e • o5
CONSTRUCTION LENDING AGENCY ` - 2 • 91300
1 � ^ `
hereby affirm that there is a construction lending agency 1 3 0 0
or the performance of the work for which this permit is - ,°'O •,
sued(Sec 3097,Civ C)
ender's Name `
0831 -81
,ender's Address
I certify that I have read this application and state that the
fbove infor -s correct I agree to comply with all County SEE'kEVERSE FOR EXPLANATORY LANGUAGE'
-
ordin s and Sta aws regulating lumbing,zp
eby
taut rize representativ s of this Count , o entthe "
a rty for ins io rpopgs
Signature of Permittee Dat