HomeMy WebLinkAbout0932A WORKERS'COMPENSATION DECIARATION � i- APPLICATION FOR PLUMBING PERMIT ��
I hercby affirm tha�I have a ceniSica�e of consent to self�, 76qyy7A "
insu�e,w a certificafe of Workers'Compensation IrrBUM�c9,. �'E 817(REV.10/81) �
or�a cer�ified copy thereof(Sx.3800,iab.c.) � COUNTY OF LOS ANGELE BUILDING AND SAFETY
.PolicyN��_a3 Compony 4i4T� FlIN� ' � - .
LjCenified copy is hereby furnishad.
� FOR APPIICANT TO FILL IN�RtINT OR TYPEJ qp�� ZO 'H, �V .
CaAified copy is filCd with the counly buildinq inSpBt-
� tion departihent. , - NUMBER HXTURE OR I1FM � FEE �«�n n
��9— �►t1-L���f�j'�Il� WATERC105ET �LSM�L
Dpfa Appli4ant - .:C��S�. O .
CERTtFICATF OF EXEMPTION FROM WORKERS' BATH Ne
COMPENSATION7NSURANCE SHOWER �R !-�E 7 �
(Thts saeHen need ne►bs eompAlad fF t�a work imoiv�d br � '
the parmN i�}or on�hundnd dollon{S100)or lets.) a uva70Rv , � AppRE55 � :
I cer�ify�ha1 i�rhe parformanea of the worlc fo.which ehb . � � -
� permil is inuad,I ahall rrol emplpyany perspn in ony mannn 51NK ' CITY � 7E1.NO. .
' m m�o beeome subjec�ro rAe Workri Gompemarivn Lcws. p�W� �
CONTRAC70N �� �
Oate � appticant qA7HE5wqSHEa - ^- .
NOtICE TO APPlIG4NT: If, aker rtaking thi�Certiiicate of A�� ��/7 S �� Ko .
Exampfion, you shwld�becoma s�biecl 10 the Worken' SWIMMING POOL RECEPNR
Gompe�+w�ion provisicro af rhe I,a6or Loda,you musl foAh- �qWN SpRINKIFR SY57FM CfTY '�T ���7/!��9L4-? �i
with comply with such prorisipn�pr Ihia permil shall be STAiE LK.
deemed rawkad. WATER HEA7ER � u���� 7 S2(. GVSS �'�
uc�NSED C9rtTRAS�DR4 Q�+RAnQN oisreicr No. raocFss�o er
J hereby affkm�hoi 1 am licemed undx proriziomof�a�ter 9 �S�T�'' �7� Q ta �
IcommerKing with S�fan 7IXq1 oF Pf►ision 3 pf!ha 8usi�+eu puTlE750VER . . y �
+eu d
and Professions Coda,and my lite�.s9 ia in fyll forcean�effen. 3 PER fiwu j VAUDATION � � �
397szlo �. B-/ - p nn� �Icel� � ,
License Number �c.tlase .
Contractor �'L 13HL"LOiNG Oata /—q►8g. t ' . � .,gyA c CsJ>� � • . V ;
� 1 am exempl vnder$ec.' . . � y •
Z �
B.&P.C.for ihis reoson Plan chetk fee �
Ddte: pLUMBING PERMIT 1$$UING fEE i !� � �
� Sigeahxe ` v .
�o,A�� y
� � Plan check applimnt ,
SING�E FAMILY �
� HOME OWNER•BUILDER OKIARAAON Name �
I hereby aff+rm tha�I am exempr from the Contrac�w's lironsa � A�5 . ��9�2 a �
Law fm�he foL'uwtny�euaon�SxHon 703i.5.Businau ond � - .
Profassions Coda: . #• • • •�•5 i
1 CiN Tel.No.
❑ I,as owner of the praperry,will do the work and the �� • � 2 4.Jr�
shucrure is no�inlended or offered fw wle�Setrion �
7044,Businns and Professione Code). , �� • � C tl,Jr Q c=.�
CONSiRUCT10N IENDING AGENCV . !
I hereby affirm�hat�here is a comhuc�ion lending egency for O I�O 9�8�4
tha pedormunce of the wwk for which this permif is issved .
(Sec.3097,Civ.C.). �
Lender's Name � �
Lender a Address � � �
I certify thol I heue read this applicalion and sfale Ihaf�he . , . . 1
a6ore Informotion is ca�ect.I agree 10 comply with all Counly
ordinances and S�ate lows regulalinq Plumbing,and hereby . '
aurhori:e representotives f rhis Caunry to enter upon the � �
obove- r�o prope� �nspxtion pu�poses. SEE REVERSE FOR EXPLANATORY IANGUAGE
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