HomeMy WebLinkAbout1294A (9) �.WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �/d� {� ;
•I hereby olfirm ihor I have a certifico+e of consent m self 76A667A � I
insure,or'o certifico�e of Workers'Compensation Insuronce, CE B17(REV.10i81) LJ
or a cer�ified copy ih(e��reof(Sec.3800,tab.C.) COUNTY OP LOS ANGELES BUILDING AND SAFETY
P❑olicy NoQ7y0Lz�jGompanySTAT� GO.y1�
Certified cop �hereby fvrnished.� /����� /
O _t FOR APPtICANT TO FILL IN(PRMT OR TVPE) qDDRESS E��O �S� Dlry'V+v / C �
Certifieo copy is filed with the county building inspec- NVMBER FI%TUREORREM �D FEE
tion deporlmenl. (� �p�p,��ty D�/V�QN �
Date
�_L u J APPlicant�✓ LD�LE�Z WATER ClOSET � NEAREST ),�J�nw�
CERTIFICATE OF EXEMPTIQN FROM WORKERS' BnTH TUB CROSS ST. V��J`� �
� � COMPENSATION INSURANCE OWNER �r� �LLQUL-i AN
(Thft aaclio�na�d nof b�cempl�l�d IF th�work invol�od by SHowER �IL
Ih�p�rmll�f}er ens hundrod dollcrt�5100)or la�s.) Lnvn70RV 6 AODRE55 � � E � �
I cnriify that in the periormance of the work for which this
permit is iss�ed,I sholl not Employony pa�son In ony manner SINK . CIN �Jf lOs TEL.NO2�3 6S7 .
so as to betome subject to�he Workers'Compensolion Laws. D�SHWASHER
� 7� GONTRAGTOR �r � '��
-Doie A-�APPIicoM � l�lJ�-��IU Z� CLOTHES WnSHER � 7�� .
NOTI TO APPLICANT: If, afler moking this Cerlifica�e of .nDDRESS �
� Exem lion, o� ehould become s�b'ect to the Wwkers' SWiMMiNGPOOLREGEPTOR y,'
P Y � �ar C. . `1L�D6 ��.�L.3� b b�
Compensalion pravisions of fhe labor Code,you must forih- �,qV�N SPRIfJKLER SYSTEM �
i1h comply Ih such p�ovisions or Ihis permit,shall be STATE 7 LIC.
deemed revoked. WATER HEAIFR ���NSE NO. � ' � � CLA55 �
IICENSED CONTRACTORS DECLARATION DiSTRiCT NO PROCESSED BY
I hareby offirm thot I om licensed�nder provisions oF Chopler 9 GAS SYSTEM WTIETS l0
(commenting wi�h Secuon 7000)of Division 3 of the Businass OUTtETSOVER .
ond Professions Code,and my licanse is in full force ond effett. 5 vett SvStErn FINAL V IDATION
C DATE � a�
license Number �+ O lic.Closs� FIN O � U,
�
ConhaUor MDro � Date " �� BY O
� ❑ I�m exampt under Set. V
P.C.for�h�s reason plan check fee ► �
Dale: p�UMBING PERMIT ISSUING FEE E � � Z
. nature
, TOTAL iEE 2 5'� �1 2 9.4 A
y � Plan chack opplim�� +y*' ° ' ' "�
I SINGIE FAMItY
� HOME OWNER-BUILDER OECIARATION Name I • •2 Z rJ O
II hereby affirm thm I om exempt from�he Contrattor's License 4.I�.o« -��-�-'� • a e_i.�(1.'_.
Law for�he fallowing reason�Sectian 7031.5,Business and
Pro{essions Code): Ciry - ------"—' Tel.No. �9.�2—$7
❑ I,as owner oi�he property,will do the work and rhe �
structure�s not in�ended or offered io�saie�Section � ►
JO<d,Business ond Professions Code). _
.ONSTRUCTION LENDING AGENCY . ' . . . .
I hereby nffirm thot there is a consir�clion lending agency for .
1he performonce of Ihe work(or which this permit is issved . �
� (Sec.3097.Civ.C.�� .. . . . .. , _ .
Lender's Nomn NQ LE n.�z'�E iZ
� Lender's Address _
I cerfify�hot I hove read this applico�ion ond stote thot the ►
above in(ormo�ion is correcl.I agree to comply with oll County
ardinances and S�ate laws reguloting Plum6ing,and hereby
authorize represemaiives oi rhis County to enter upon fhe
a6 e•meNioned p perty for inspeclion porposes.
SEE REVERSE FOR EXPLANATORY IANGUAGE
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