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HomeMy Public PortalAbout9556 BROADWAY_Plumbing__ WORKERS'COMPENSATION DECLARATION l� FOR PLUMBING PERMIT I.hereby,Cffirm that I have 6 certificate of consent to self.in "4.16-00k,5 DPW 4�� - i'1 IL P'i tlrl 64J19H9 II\7 7H6 �7 sure,or a certificate of Workers'Compensation lnsuragce,ora - - - - - certified appy thereof (Sec 3mpa Lab. C. COUNTY OF LOS'ANGELES DEPT..OF PUBLIC WORKS . Policy No. Company - Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN(PRINT OR TYPE) - BUILDING - 0 Certified copy is filed with the county building inspection ADDRESS Lf (/Q'�Il vYxA�(l4j• department. .NUMBER FIXTURE ORITEM @ FEE LOCALITY WATER CLOSET(TOILET) ✓ t..C� I Dote Applicant -� r / NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS', BATH TUB CROSS ST, COMPENSATION INSURANCE OWNER (This section need not be completed if the.work involved by SHOWERMAIL the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS f I certify that in the performance of the work for which,this per- r / mit is SINK CITY issued, I shall not employ any person in any manner so // TEL..NO. `2y9&41(7 C as to become subject to the Workers'Cam pensation Laws. _ DISHWASHER ' i• CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY TEL. NO. sation provisions of the Labor Code,you must.forthwith comp- 'LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE LIC. , ed. - WATER HEATER LICENSE NO. CLASS ' LICENSED CONTRACTORS DECLARATION - DISTRICT NO. - PROCESSED BY I hereby affirm that I am licensedunder provisions of Chapter GAS SYSTEM OUTLETS T 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL JI VALIDATION fect. / HOSE BIB DATE License Number Lic. Class a0 FINAL V Contractor Date BY G I am exempt under Sec. - �Q 0 U B.BP.C. for this reason Plan check fee D a N Date. PLUMBING FERMI T.ISSUING FEE$ Q - z . Signature _ TOTAL FEE SINGLE FAMILY - HOME OWNER-BUILDER DECLARATION Plan check applicant - 5 I hereby affirm that I am exempt from the Contractor's License Nome Law for the following reason (Section 7031.5, Business and ACCT." Professions Code): Address - �1 -s owner of the property, eo the work and the City - - Tel. No. structure isnot intended or offered for 3,303 204.40 d for sale(Section 7044, 1 ITEM5 Business and Professions Code). - © TOTAL 204 . 40 CONSTRUCTION LENDING AGENCY. - CHECY, 204.40 Thereby affirm that there is a construction lending agency for - CHANGE ,OC the performance of the work for which this permit is issued - (Sec. 3097, Civ. C.). - -Lender's Name 0000-0001 1/ 8/96 Lender's Address 4132 1 AM11:27 I.certify that I have read this application and state that the above information is correct. I agree to comply with all County D ordinances and State laws regulating Plumbing, and hereby authorize representative of this County to enter upon the above-mentioned property for inspection purposes. - � �( SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee v Date