HomeMy Public PortalAbout6012 IVAR AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76a667A
I hereby affirm that I have a certificate of consent to self CE: an (2-80) A PPLC A T I ON -F®R P L U M B I NG. PERMIT ,
insure, or a,certificatg of Workers'Compensation
Insurance,or
a certified copy thereof(Sec.3800,Lab.C.) u
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. - Company JJJ
Certified copy is hereby furnish fl/4 —FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Je /
�/ NUMBER FIXTURE OR ITEM O FEE ADDRESS
Certified copy is filed with th county building inspection
LOCALITY
flepartment. - WATER CLOSET v � � -' �•
Date Applicant NEAREST y� r
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER - OWNER ° a
LAVATORY MAIL - }
(This section need not be completed if the work involved ADDRESS a
O
by the permit is for one hundred dollars ($100) or less.)
SINK CITY TEL.N0 U
I'certify that in the performance of the work for which this DISHWASHERIL
permit is issued, I shall not employ any person in any manner CONTRACTOR - 0
so as tobecome subject to the Workers' Compensation Laws. CLOTHES WASHER U
ADDRESS
Date Applicant SWIMMING POOL RECEPTOR CL
NOTICE TO APPLICANT:'If, after making this Certificate of CITY TEL. NO. Cn
Exemption, you should become subject to the Workers" LAWN SPRINKLER-SYSTEM STATE LIC. Z
JCompensation provisions of the Labor Code, you must forth- LICENSE NO. Z CLASS
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. DISTRICT NO. PR CESSED BY
GAS SYSTEM OUTLETS _ r
LICENSED CONTRACTORS DECLARATION OUTLETS OVER ( �
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of.Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE � .� 3
effect. ......!!!
r FINAL
License Number Lic.Class BY
Contractor Date
I am exempt from the licensing requirements as I am a Plan check-fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ Crt
-acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE t -
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's ?ddress z 4 b .A
' License Law for the following reason (Section 7031.5, Busi- City Tel.No. # o Fo o o 0 2.•
ness and Professions Code):
aI, as owner of the property, am exclusively contracting210 l0 2'(,I 5 Q r
with licensed contractors to construct the project
(Section 7044,Business and Professions Code). opo 2`G,5 Q:=
o-
CONSTRUCTION LENDING AGENCY Q.5.2 81-82
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
Lender's Address_ r
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 property for inspection purposes.
Signature of Permittee Date.