HomeMy Public PortalAbout5715 ROWLAND AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION1
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I hereby affirm I, e a•alertificate of consent to self ae a» z-ao) APPLICATION ICOR PLUMBING PERMIT
insure,or a certificate oT WorAnis Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS
Certified copy is filed with the county building inspection
NUMBER FIXTURE OR ITEM • FEE
department. WATER CLOSET LOCALITY
Date Applicant '— NEAREST OAK-
- L/114 Od
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. —j�,,,
COMPENSATION INSURANCE n- OWNER
SHOWER �
(This section need not be completed if the work involved !� LAVATORY MAIL /
ADDRESS
by the permit is for one hundred dollars ($100) or less.) c7 }
/ SINK CITY A_Mj/�fC �fj TEL.NO. �� O
I certify that in the performance of the work for which this DISHWASHER CONTRACTOR ClV V
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER �"� Cr
ADDRESS O
Date Applicant SWIMMING.POOL RECEPTOR I—
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. W
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. N
Compensation provisions of the Labor Code,you must forth- LICENSE NO. CLASS
with comply with such provisions or this permit shall be. WATER HEATER
deemed revoked. GAS'SYSTEM OUTLETS DISTRICT NO. PRO EBBED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER ✓
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code,and my license is in full force and DATE
effect.
FINAL
License Number Lic.Class BY
Contractor Date
El I am exempt from the licensing requirements as I am a Plan Check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE 15-25 5 B 8 A
Lic.or Reg.No. Date .Plan check applicant
0 0 0 0 0 5
HOME OWNER-BUILDER DECLARATION Name 2.0 0 48 5
I hereby affirm that I am exempt from the Contractor's Address _
License 'Law for the followingreason Section 7031.5, Busi- o,c o ((.a 5 0 c0
( City Tel.No.
ness and Professions Code):
0�I, as owner of the property, am exclusively contracting 0812-82
with licensed contractors to construct the project
(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
ordinances and State regulating Plumbing, and hereby
authorize re resents ' e of this County to enter upon the
aboxe- tuned p p ty fo 'nspection purposes.
ignature f Permittee Date