HomeMy WebLinkAbout0793A (6) WORKERS'COMPENSATION DECLARATIpN
APPLICATION FOR PLUMBING PERMIT �
I heroby aNi.m rAat I ho!4a a cemfica�e oi comen�to xlf .� �6pbyq �
insuro,o.a cer�ificare of Wpken'Compensoiion Insurpnce, . CE ai7�REv.i0iai) � . .
or a ce.tcfied copy�hereat(Sec.380Q, c.) r 4 COUNTY OF LOS ANGEIES BUILDING AND SAFETY
Po�IicyNo.7���ompany ��cr �
Cenified wpy ia bereby furnished. ,
FpR APPLICANf f0 FiLL IN�PRIM OR TVPE� �� � U„0
� Certified co ia filed wuh�fie ,ty building' c- � . :
tiondepOrt�nl. . NUN�BER FIXTUREORITFM � � �Q(pGITY � . .�
Date APP�'Gant WATER C1Q6ET NE4REST
CERT�EXFMPTION fROM KYDRKE ' BATH TUB Ck035 ST. G�L It �
G'OMPENSATtON INSURAtJI� �ER puyNER uJ� �5 . i
(ThI�sMlon neal no1 bs eompl�led ff Th��rrerk ie�olwd by ,yy�a '
th�permlt b fer en�hundnd dollen(51001 or I��s.� , S wvnro¢r qppRESs D
I�ertify�ho�in�he parfpmrance ef Ihe wotk for whirh�hi� - �
permit is itwed,I sholi no�employ any penon in any monner � S�K F�-00� �0 � Gn ��'�'' �
so as�o become subjxt�o�he Waken'Compa'nafion lows. � �M R�� p�l G �
d COMRAROR �+
Dare � a��icant .. - C10THE5 WASHER .
NOTICE TO APPIIfJLNT: If, oifet maki�g this CerTifitnTe o4 A�� Z a ���1 `S
Exemplion, you should become subje[1 ro fhe WOrkers' ����'P���R CITY �0 TEt.NO.
Campensation paAsio�n a1�Ae latwr Code,you mui�fonh- �pwN SaRiNK�ek srsfEM C' �"� ��'� Q�iS D C� �
�with wmply with such pro.isiom rn IF�ia permi�shait be SfATF t�C. .
deemed rovoked. wwT[aHe,ahtt uc�vse No. � t�G cuss G�3�s i
.. UGFNSED CONTRACTORS GECI,ARATION i � rnsrnKT No. oRocEsSEo sr !
cns svsrenn ourters i
1 hemby affirm dmt I am liFePwd�tder pwiaions of pnprer 9 17 V I D � } �
(�rnmmtci�g vtith Sectiota 7000)of D'rrislpn 3�me Business OUilEt50VEa � a
ond Profess�ona Code,and my license����full force ard eHect. S vE�+sr51�n fINAL VALIDATION V �
4.I'��fl5 �: ��� l UQ,IN, DAh �� �
License Number��_.�...�c.Class^�0.. �
�� S �Loo a �� � i
Contmctrn����( ��'�Oote� ! 3 Q onh� r•tK (� �
�� I am exempl ur�M Set. - t�n �
Iv�oP Sti Z �
^ .- B.BP.C.for�h:s reoson p�pn check fQe ► d
I
O°�B� MUMBING VERMIT ISSUING FEE S r!� S
r� g�4^aw", � i
rorx�r� �
_ P���,«k a,��;�a�� �c��.�n �
SINGtF FAMIIY
HOME OWNER-BUIIAER OECiAR.4T10N Name • . . . �i. e e o a 5
I heroby offfrm rhat I am sxemp�from the Conhacb�'s Licenae �d�� ; _ i 'u J� �
Larv lor the followirg reamn(Section 7031.5,B�s�nees ond - � " �� +
Profesa�orn CodeE: - Ci Tei.No. . � �
❑ I,as owner of the propeny,wi�l do the work and the � � � � , ��`�r� ��
ahucturo q not intended or offered for sale �Sedion ► u��� S—�i O ��
7044,8usinns ond Profeasione Code). �
CANSTRUCTION IFNDING AGENCV - . I
I hereby affirm�ho�there is o consnuction lardiag agency for � �
t�e perfmmance of the work for which thi�permil is issoed . i
(Sec.3097.Civ.C.�. . . �
Lender's Nome
1
lender i Address !
�I certify tha�I Vwve reod this applimtion and sta�e ihat rhe � ► i
a6ove inforrtw�ion is cmect.I ogroe lo comply with oll Co�n1y . �
ordinances and Srafe lows regula'ng Plumbing,ond hereby �
au�Aorize repesentatives of hi oua�y to eMer opon the ' -
1
abov - en��on r1y pec�ion purposea. SEE REVERSE fOR EXPLANATORY IANGUAGE ' �
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