HomeMy Public PortalAbout5303 SANTA ANITA AVE_Relocation__ WORKER'S COMPENSATION DECLARATION ! 7BAA667A PW 9/89 ���������®� ®� PLUMBING
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I hyreby'affirm that I have a certificate of consent to self insure, L{,IUM tl IL JI
or a certificate of Worker's Compensation Insurance, or a certified y
copy thereof(Sec.3800 Lab.C.) ,
Policy No.-7-0,164_& Company
C.��. T� �u��� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
❑ Certified copy is hereby furnished. BUILDING
� FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS In /1 �— •Ir77
Certified copy is filed with the county building inspection s'5411
department. I NUMBER FIXTURE OR ITEM @ FEE
--f � LOCALITY
Date — ?A�pplicant ; WATER CLOSETf
NEAREST
CERTIFICATE OF EXEMP N FROM WORK CROSS ST.
COMPENSATION INSURANCE I BATH TUB
ASSESSOR
(This section need not be completed If the work Involved by the SHOWER MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) i OWNER KOH
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as to I SINK ADDRESS MAIL �
become subject to the Workers'Compensation Laws. �� ��r
DISWASHER CITY A
TEL.NO.
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Co1
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS 7 ``7
provisions of the Labor Code,you must forthwith comply with such V
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY j TEL.NO. }
I hereby affirm that I am licensed under provisions of Chapter 9 STATE LIC.
WATER HEATER C ��I` _ 0.
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. CLASS �— V
Professions Code,and my license is in full force and effect. e�
OUTLETS OVER DISTRICT NO. PROCESSED BY
o�
License Number� � Ll..Class 5 PER SYSTEM
o
f (� FINAL
DATE VALIDATION Ill
Contractor Datecc
�,�
❑ INAL 2
I am exempt and r Sec. BY
B.&P.C.for this reason
Date:
Plan check fee
'
Signature PLUMBING PERMIT ISSUING FEE$ aLf 7�
❑ TOTAL FEE
J Plan check applicant
SINGLE FAMILY
Witx
HOME OWNER-BUILDER DECLARATION Name
I.hereby affirm that I am exempt from the Contractor's License Law 1
for the following reason(Section 7031.5, Business and Professions Address
Code):
�City Tel.No. '• •�I=''•�
F1I,as owner of the property,will do the work and the structure r
is not intended or offered for sale(Section 7044, Business , .,,�,6:•,•}
and Professions Code). ('.f 11--;yI
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 -: :j- h ,5 a._
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 ordinances
and State laws regulating Plumbing, and hereby authorize
representatives of this County to enter upon the above-mentioned
Proper or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ;
nature of Per to Datb