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HomeMy Public PortalAbout5933 1/2 PRIMROSE AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76AG67A I hereby affirm that I have a' certificate of consent to self cE e17 (:-6e) APPLICATION FOR' PLUMBING PERMIT insure,or a certificate of Workers'Compensation Insurance,or , a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOSNGELES (� BUILDING AND SAFETY Policy No. ZZ'9� mpany �gI�' L�lo7,+?' L_C?Cak- t�3�ii o F1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING E] Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE AD department. WATER CLOSET LOCALITY DRESS %%A L� GST Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 14 CROSS ST. uJdC4©v_UiaF COMPENSATION INSURANCE SHOWERtqQ&Z 4p> CC> OWNER LAVATORYOt'3 MAIL } (This section need not be completed if the work involved ' ADDRESS e. by the permit is for one hundred dollars ($100) or less.) SINK CITY TEL.NO. I certify that in the performance of the work for which this DISHWASHER permit is issued, I shall not employ any person in any manner CONTRACTOR so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS Date Applicant SWIMMING POOL RECEPTOR NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO M.r / Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Z Compensation provisions of the Labor Code, you must forth- WATER HEATER LICENSE NO. CLASS with comply with such provisions or this permit shall be deemed revoked. DISTRICT NO. PRO ESSED BY � GAS SYSTEM OUTLETS LICENSED CONTRACTORS DECLARATION OUTLETS OVER ��o� I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi- FINAL ness and Professions Code,and my license is in full force and VALIDATION DATE J effect. FINAL (� License Numb r Lic.Class � BY Contract or Date !i 17— 2Z�— Q ElI am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ Sta acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE �O 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- Tel.No. 2 9 9,4 A ness and Professions Code): 1, as owner of the property, am exclusively contracting ' 0 0 0 0 0 5 with licensed contractors to construct the project 2 o 0 2(j,5 0 (Section 7044,Business and Professions Code). i CONSTRUCTION LENDING AGENCY 0 0 0 2 4 5 0 I hereby affirm that there is a construction lending agency 2 8—$2 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 ordinances and State laws regulating Plumbing, and hereby i authorize representatives of this County to enter upon the �bove- tinned pro arty for ins action purposes. ignature o ermittee Da e � r