HomeMy Public PortalAbout5934 IVAR AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION zsasetA
'I hereby affirm that I have a certificate of consent to self cE e17 (2-60) A� L I C A T�®N FOR P L U M B NG P E R W
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insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,La .)
COUNTY OF LOS ANGELES _BU ING AND SAF Y
Policy No. Company
F Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) ' BUILDING
EADDRESS �
Certified copy is filed with the c unty g inspection NUMBER FIXTURE OR ITEM O FEE .
de r nt buil LOCALITY
Date Applicant WATER CLOSET
NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKE S'
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL.
(This section need not be completed if the work involved ADDRESS }
by the permit is for one hundred dollars ($100) or less.) SINKa
CITY TEL.N� O
I certify that in the performance of.the work for which this DISHWASHERU
permit is issued, I shall not employ any person in any manner CONTRACT R
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER Jel
ADDRESSAJO
Date Applicant SWIMMING POOL RECEPTOR ,�/ ~
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. N `��� U
W
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM a
Compensation provisions of the Labor Code, you must forth- STATE LIC. ! to
P P .rl LICENSE NO. CLASS. C.' p Z
with comply with such provisions or this permit shall be WATER HEATER (/G/
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY
LICENSED CONTRACTORS DECLARATION
OUTLETS OVER jz
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of•the Busi- @ FINAL , VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect.
FINAL
License Numbers2 /31V_Lic.Class G3 /o BY
Contractor'? Date Q�/
`„--•
ElI am exe pt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING.FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lic.or Reg.No.' Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
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 contractingq �. CI M' z b 2 b R
with licensed contractors to construct the project
(Section 7044,Business and Professions Code). � �''o•o•�o00_CONSTRUCTION LENDING AGENCY VIP&.
I hereby affirm that there is a construction lending agency ,2,0 o 1.2 5 0
for the performance of the,work for which .this permit is _ _•
issued(Sec. 3097,Civ.C.). 0
� o 0 0 2 5 Q v
Lender's Name 0 9, 1 6i-82
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 th ounty to enter upon the
above-mentioned property for ' sp tion purposes.
SignaturV Permittee I 01te