HomeMy WebLinkAbout1727 SILVER RAIN DR (5) —� WORKERS'COMPENSATION DECLARATtON APP�,'�,AT�oitl FOR P�UIF/EBI�V PGLEitlC�T � �
I hereby affi�m that I have a ce�tificate of consent ro self �bqby�q �
insure, or a certificate of Workers'Compensatian Insu�ance, CE 817(REV.IOi81) +'.
or a cerrrfied copy the�eof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BU{LDING AND SAFETY I
P❑ol�icy Na. Company `
Certified copy is hereby fumished. BUI��WG �j�f /� i
❑ FOR APRICAN7 TO FILL IN�PRIM OR TYPE) AD�RESS �/L SJ�Z(���'�T � � �
Cer�ified mpy is filed with ihe munly 6uilding inspea
tiondepartment. NUMBER FIXTUREORITEM [� FEE
LOULITY ��O
WATER CLOSEi �^
Date Appli4ant CeOSS ST/,I T� ��C���'L�, �
CERTkF4CATE OF ExEMPTION FROM WORKERS' BntHiUB
COMPENSATION INSURANCE SHOWER OWNER�M ��
(This sacFion nwd wot Iw eompFefed if Nte work involred bp
th�p�rmM Is For eiw h�ndrvd doklqrs(5100)or iws.) tnvq7oRr �'�� /^� ��t
~ ADDRE55 l !� � .
f certify that in the performonce of the work for which this
permit is issued,�shpll not employ any person in nny monner SINK CITY � p.�,oN3 f� TEL,NO.��//..7�
so os ro become s�bjecr to the Workers Compensation Lows. ���
DISHWASNER GONTRACTOR
Dat �2'Z� pplicant����'N��y� C�OTHESwnSHER �� �
NOTICE TO APP ICANT� If, after making this Cenificate of AODREu j
SW�MMING POOL RECEPTOR
Exemption, you should becnme su6ject ro the Workers' F
CITY 7EL.NO. 1
Compenwiion provisions of the Labor Code,you must forth- r
with compfy with such prouis'rons or this permit 5holl be �AWNSPRINKLERSYSTEM STATF !
deemedrevoked. ���
WAFER HEATER LICENSE NO. [�qg$ 'y
LICENSED CONTRACTORS�ECLARATION DISfRICT NO. ESSE�BY �
I hereby a4firm Ihcxf i om licensed under pror:sions of Chopter 9 GAS SYSTEM OUTLEfS 0 �O P j�J i
(commencing with Sedion 7000)of Division 3 of the Business OU7tEi50vER � �
and Professions Coda,and my license is in ful�for�e a�d effe<�. 5 vER SYS7EM � F
�Q p�� .�� 3 YAtiDATIpN u
s'
License Number Lic Ciass �, d
PINAt :
Contractor Dale 8Y � (;�,,�-?y-�r� V ?
� I am exemp�under Sec. y �
8.&P.C.4or fhis reason plan check fee � E
:
Date: PLUM64NG PERMtT FSSt!!NG FEE$
Signature �� �
TOTAL FEE y� }
. Plan check oppikant i
SINGLE FAMILY s
HOME OWNER-BUILDER DECLARATION Name t
f hereby offirm that I am exempt from the CoNractor's License
law for the following reason (Section 7031.5, Business and pddress c?f,GS/� F. F
Professions Cade): " `S
� City Tel.No.
�'.• r s • •S �
I,as owner of the prope�ty,will do the work and the
structure is not inrended or offered for sale (Section � � • •�C.�`.
7044,Busineu and Professions Code).
CONSTRUCTION LENDING AGENCY • ° �'��v i'� �
I hereby atfirm ihat thare is a construc�ion lending ogency for �
tbe performonce af Ihe work for which this permit is issued ��C�'��� -
(Sec.3097,Civ.C.). €
's
Lender's Name a
�
lender's Address . �
1 certify thpl I hove read this applicotion ond stote�hol�he �
abore informofion is to�rect.I ogree Io comply wilh all County �
ordinances and State laws r arin mbing,and hereby
aut orize representatives � un �o enter on�he � �
a ve-mentioned pro f i � n purpos
� ��/ SEE REVERSE FOR EXPIANATORY LANGUAGE i
6�`.�'77�
Signature of Permittee Date 3
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