HomeMy Public PortalAbout9160 EMPEROR AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION' AA867A ,
I hereby affirm that I have a certificate of consent to self cH e17 (z-ea) APPLICATION FOR PLUMBING PERMIT {�
insure, or a certificate of Workers'Compensation Insurance,or �J
a ertified+�copy thereof(Sec 3800,Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
o i Fd —!?Company��h
Certified copy is hereby furnished `�— r FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
Datedepartment Q LOCALITY
Apphcant�Q�7tX+___ WATER CLOSET -/ NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER _ OWNER I
LAVATORY MAIL
(This section need not be completed if the work involved 5 ADDRESS CA-
by
by the permit is for one hundred dollars ($100) or less) SINK CITYTEL NO
I certify that in the performance of the work for which this DISHWASHER tr
permit'is issued, I shall not employ any person in any manner CONTRACTOR p
so as to become subject to the Workers' Compensation Laws / CLOTHES WASHER ADDRESS (~j
Date Applicant SWIMMING POOL RECEPTOR0.
NOTICE TO APPLICANT If, after making this Certificate of CITY TEL N44Y-'22.94to
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC
Compensation provisions of the Labor Code, you must forth- LICENSE NO CL-APS
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DIST_ CT NO P OCESSE BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL �] 3 VALIDATION
ness and Professions Code, and my license is in full force and DATE r
effect —
FINAL Zk_
License Number is class� BY
Contractor Date
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code) i TOTAL FEE - ;? l 43.0 A
Lic or Reg No Date Plan check applicant # o 0 o 0 o 5
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address J
License Law for the following reason (Section 7031 5, Busi- City Tel No
ness and Professions Code)
I, as owner of the property, am exclusively contracting
with licensed contractors to construct thea project 2 0 0 5 8,0
(Section 7044, Business and Professions Code)
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CONSTRUCTION LENDING AGENCY o io o Jr 0 v
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 10,05-81,
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned propertyjfor inspection purposes
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Sig ture o P tt a Date