HomeMy WebLinkAbout0304 0612A WORKERS'COMPENSATION DECLARATION ppp�fCqT1dN FOR �'!lJ��ING �'ERMIT �
I hereby otfirm!hot I have a certificate of consent to self �6,q6y7q
insure,or o certificole of Workers'C pensa�ion Insurance, CE 817(REV.10/91)
or o ce�tified copy�hereof(Sec.3B ob.C.� COUNTY OF lOS ANGELES BUILD{NG Af3D SAFETY
P�o-I�icy No.���Company .
Certified copy is here6y furnished.
FOR APPUCANT TO FIL�IN(PRINT OR NPE) BUILDING Q ��� �V, S
C rtifie mpy is filed with ihe m bu' ' speo- AWRESS �'��.Vi•' l
�fi n de rimenf. NUM iiXTUREORITEM � FEE
LOCAUTY �
Dat AppliS t WATER CIOSET Q� �qREST / t+
ERTI CATE OF EMEMPTIQ ROM WORKERS' BAtHTUB CRO5557. �}.� f w v�,,1
COMPENSATION INSURANCE pyyryEg � '
(Ehir sxtiort n�d nof bQ eompiv►od if Ihv wosk involvad�y SriowFR
tho parmle is br onr bundr�d dollars(i100)or lo�s.) tAV.4loev � MAII
A�ORE55
I tertify thol in Ihe performance of the work for which this ',
permi�is issued,1 shall not emp�oy any person in any manner SiNK Cltt TEL NO.
so as ta become su6{ect to the Workers'Compensatian Laws. �,R '��
CONTR.4CT0 � i
DPt¢ Applicpnl CIOiHES WASHER qppRE �
CE TO APPLICANT; If, ofter making this Certificate of D� j
�p��on, you shouid be<oma subjea to �he Workefs' 5WIMMINGP00€RECEPTOR �
� �ompanaatiort proviaiorta of the lo6or Code,you mvst forih• � TEL.N0.
LAWN SPRINKLER$YSTEM i
with comply with soch proviaions or this permit shall ba STA / �I�, �� ?
deemedrevoked. WATERHEATER ��� • �-�' + ���N� ' �P cwss j
LiCENSED CONTRnCTORS DECIARATiON OISTRICT NO. PROCESSED BY �
I hereby aifirm tfwt I am lica�sed under provisions of Chapter 9 GAS SYS7EM OU7LETS � �
(commencing with Section 7000)of Division 3 of the Bosines OUTlET50VER �
and Professians Code,and my license ie in fuH force ond effeci 5 PER SYSTEM ����
� � vauaAria+� ,:,�
Llcense Nu Lic.Class � � � DATE ��-��� Q�
. r+I FfNAL 0`j Q L�' V'
ContraUor Date �f iQ �A�� B� „�/ � `r �.;
� Q C7 � o;
1 am ezempt under Set. Q �� a. � U�
8.8P.C.fw ihis reason , y,��
Plan chec fee � f 7, 0—� p,�
Dota: � fA:
PLUMBMG PERMIT t55UfNG FEE$ Z:
Signature �1��O��` ���
TOTAL FEE g"Q � 1
7
Plan cbeck nppiicant �
SINGIE FAMIIY
HOME OWNER-BUIIDER DECLARATION Nome
.�by affirm that I am exempt from the Contractor's License
� L w for the fottowing reason(Sec�ion 703t.5,8usiness and a�`� ' � � ' � �
Professians Code): Ciry Tel.No.
❑ I,as owner of ihe property,wi41 do the work and thC
strodure is nor intended or offered for wle (SeUion - �
7044,Business and Profesvons Code). z G b�,�R
CONSTRUCTION LENDING AGENCY
I hereby nffirm that Ihere is a construction lending agenty for �• • • • •5 �
the performance of the work for which this permi��s issued � •d 7 a 5 Q �
(Sec.3097,Civ.C.).
Lender's Name • F�7��V W� }�
Lender's Address O��, 2 r 8 7 !
I cerirfy that I have read fhis applicaiion and srafe iho�the � '
above informalinn is correct.I ree�o comply with oll Counly 1
ordinances and Sfate laws �ating Plvm6ing,and hereby i
authorize repreienlohves f t is CouNy t enter upan Ihe �
above-me ' ed pr ty fo mspectivn p rpose
�� (�� SEE REYERSE FOR EXPIANATOitY LANGUAGE f
d ,
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