HomeMy Public PortalAbout9584 LOWER AZUSA RD_Plumbing__ WORKERS COMPENSATION DECLARATION 76AG67A
I hereby affirm that I have a certificate of consent to self C6 $17 12 80) APPLICATION FOR PLUMBING PERMIT
insure or a certificate of Workers Compensation Insurance or
a certified y thereof(Sec 380o L.Ab, C) COUNTY OF LOS ANG LES BUI LD D S ETY
Policy No 7Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) ObUILDING / / e,
Certified o y is filed with t ounty ing i ction NUMBER FIXTURE OR ITEM • FEE ADDRESS J �/
d7 WATER CLOSET LOCALITY � /`f
Date Applicant NEAREST
BATH TUB CROSS ST
C TIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved LAVATORY MAIL
ADDRESS
by the permit is for one hundred dollars ($100) or less) SINK a
CITY TEL NO 0
I certify that to the performance of the work for which this DISHWASHER V
permit is issued I shall not employ any person in any manner CONTRACTOR
so as to become subject to the Workers Compensation Laws CLOTHES WASHER O
ADDRESS
Date Applicant SWIMMING POOL RECEPTOR W
NOTICE TO APPLICANT If after making this Certificate of CITY5At L NO
Exemption you should become subject to the Workers LAWN SPRINKLER SYSTEM .l y
STATE ,{ 2 LIC 2
Compensation provisions of the Labor Code you must forth LICENSE NO t� 7 CLAS V% z
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DIST e"T NNO� O SSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER ��
I hereby affirm that I am licensed under provisions of Chapter IS PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi FINAL VALIDATION
ness and Professions Code and my license is in full force and DATE
effect FIN�J
License Number is Class 1 BY AL
L
Contract ate
L i
F1 I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) TOTAL FEE
Lic or Reg No Date Plan check applicant ;90202A n
HOME OWNER BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractors Address
License Law for the following reason (Section 7031 5 Busi City Tel No 2 • • 22-00
ness and Professions Code)
0 I as owner of the property am exclusively contracting * 22005
with licensed contractors to construct the project 0615-81
(Section 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
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
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
ordinance and State laws regulating Plumbing and hereby
authonz representative f this County to enter upon the
abov ntio pro for inspection purposes
.1 &-6
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404 Z_'16 &
/3116tuff 6f Permittee Dat