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HomeMy WebLinkAbout1242A (11) . i WORKERS'COMPENSA710N DE�LARATION ,qpp�.{CATIafi1 �OR PLUA�AB1i�G PERii�IT � ; i here6y,offirm thoi i have o certificate of consen�ro seif 78A867A � , insuro,or a cartifitote of Workeri Compenwtion Insvrante, CE 8f7(REV.8/86} . 3 cr a cerrified copy ihereof�Sec.3�ab.C.) i P❑ol�cy��_company C�UNTY OF LOS ANGELES DEPT. OF RUBLIC WORKS � Certified topy ia heroby furnisF+ed� ! � FOR AP�IiCANT TO FILL IN(PRINT OR TYVE) B���w� 3 i Certitied mpy ia filed with the caunty building inapet- /�� k tion d�eporlme� NUMBER FIMUREOR ITEM � FEE � 3 i ���� WATER CtOSET ; Dale Apppqant NEAREST CERTIFICATE OF EXEMPTIQN FROM WORKERS' BATH TUB CRO55 ST. ; COMPENSATION WSURANCE OWNER 4 (Th1s s�ctlon nwd nof In cornplNrd if Ih��rork inrolv�d by �OWER flw parmtf Is for ona 6uedrwl do{(ars(=100)a ks�.} wvaiOkv ��� I certify fhal in the performance of the work fo/which this ADORESS permit is issued,1 shall not employ any penon in any monner 51NK p7y �,ryp, j so m�0 6amme cub�ecf to the Workers'Compensotion Lows. ` DISHWASHER CONTRACTOR ! �IR � ��1(`�'••^�� CtOTHE5WA5HER ' ADDRE55 � ; :E TO APPIfCANT: If, aftar rrwking Ehic Certifiwle of ' D• � ' �ption. You shoutd become wbjecl ro��1he Wakrs, Sw�MMING9�.RECEPTOR . c�n 7EL.NO. � Compensafion p�avisions of the lobor Code,yov mvsi forth- �e,WN SPRINKLER SYSTEM - wilh comply wilh such proviaions or this permit shpll ba STqTE : IIC. deemed revoked. WATER HEATER LICENSE NO. �Q CLAcS �" < < 410ENSED COMTRACTORS DECLARATION DISTRKf NO. VROCESSED BV � 1 hereby aff'rcm rhat t am(icemed�nder provisio�n of ChapFer 9 GAS SYSTEnt Ot}TlEiS - (commencing wi+h Sectivn 700D)-ot Division 3 af the Bnsiness purtErSovER � g and Proiessiona Code,ard my license is in f�ll force and effecf. 5 PER SYSTEM � DA EL r � VALIOATION v : t�,� licanse N�mber 3 o q A�3 �ic.Clau � 2' �l�C � � ���� L FINAL O i Coniractor�l�.k. AT•^r�Dote '� 'Q BY / F" ` � � � C {om exempt under Sec. pw, % ''zTLl4.C11 y ' B.6P.C.for ihis reason z � Plan check fee ;;.. . . .� DaFe: : PLUMBING PERMIT ISSUING FEE$ �Q � � i �G�� 3 Sigrwture TOTALfEE r n �=.. .,., i Plan eheck applteam e ,� r SINGLE FAMILY ����� —R 7 { �' HOME OWNER-BUItDER OEGkARAT1pN +� Nome � � i�Y ,�y oEfirm Nwt f aen�xanpt frain t!�Conhaelols Ltcams . . . . .. -:...,:.�_-..-., ,. . ..: ,. � � :„ . . . � ......��:::... .................. . .. .�:... ' 16w for�the folbwing rcason(Sectton 7031.5,Business ond Addross � � � � Profeuions Cvde�: �iy Tel.No. ❑ I,as owner of the propeny,.wil4 do the work ond Ihe sMucfuro is not inSended or oHered for sale(Saction � j 70aa,Bufiness ond Professions Code). � �ONSTRUCTION LENDING AGENCY I here6y offirm that there is o conaNucl'ron lending agency for ; the performance of the work for hith this permit is issued (Sec.3097,Civ.C.�. � i Lender's Nome ! lender'c Address I certify ihat I have read this apptication and state that the � `• above infwmetion ia correct.I ogree ro comply wirh all County � ordinances and Siate Icws regularing Plumbing,and hereby ou+horiza rapreaentatives of this County ta entar upon the o ve-men�ioned propeny for in�4�pec�ion purposes. SEE REVERSE FOR EXPLANATORY tANGUAGE � ���,(����/f�Jc �.�/�7 ignature of ermilt p Date � i --- � - r--- .: � 1' L, � 4 = � =' O 7! C ti u O G i'D ' I '_y„ :- �.� ry ^ S O ` �b f: .iJ ,'7n C fh` ¢. 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