HomeMy WebLinkAbout1711A (17) WpRKERS'COMPEIVSATIONDECIARATION ' qppLICATION FOR PLUMBING PERMIT ��� � ?
I hereby affirm�ho�I hove o cerrificate of consenr ro eeif �bqyy�q !
i�q ur e,or o tertificote of Worken'Com p ensation Insurance, C E 8v�R E v.I Oi 87) � i
or O te{�r�(rf' copy lhereof(Se.3800,Wb.C.) COUNTY OF,LOS ANGELES BUILDING AND SAFETY
PoIi�NO���m� �Q�� :
:� Certified copy is heroby fumished. �
❑ fOR APPLICANT TO NLL IN�RtINT OR 1YFE) BV�� ��1� I
Certified copy is filed wi�h�he coynry buildi�g i pec• �R� �/2A `�� �10 Mvi/r
lio de me t. �NUMBER fIX�URE OR ITFM � PEE ��juITV '
e�fP WATER C105ET �• }
Do1e`� App1iS ^' NFAREST '
� CERTIFIUiE Of EXEM IQN FROM WORI�RS' BA7H�VB ���' �
COMPENSATION INSl1RANCE SH�R pWNFR ;
� �he�permN la tor ono hund�dollanF(5100)or Isn.}�� ip�qtp�y . q-�pp�SS
��
1 certify tho�in�he per(ormaixe afi rhe wark for which thia �A _ - i
� permil ia isaued,I shall oot employ anY R��n in cny monner `�NK- � � OjJ C�tY `�i TFI.No. . .
so as ro become subjecr 10�he Workeri Compensn�ivn Laws. Di5MWA5NER !
. . CONtRACTOR .
�
� pale � applican� � C101HE5 WASHER �E� i
, NOTICE TO APPIICANT: If,afiter moking thia CeAificare ai � d +
Exemprion, you sho�ld beeqme ,ybian �o rhe Workers' '�����'���� �ry,tp Tq'Hp 2 �
- Compenso�ion provisions ot the labor Code,you mus�fonh- � �7f i
� wilh Gom wiih eu[h w��NKIFR SYSIFM
Ply provieiona w this if shail be
� deemed rovoked. �m WATER HFAIFR O��ll E1u5E tv0. �. � C�iaSS �' 1
� - LI�NSED QDNLRAC70R5 DE�4pf{ATION ' DISTRICr NO. SSEDBY �
� I bereby affirm fhot 7 om li[en;ed urder prortsivlq.Qf�Glwpfer 9 �5�� � � ��T� !� t� �
� (wmmencing wlth Secrion 70001 af�ivislop 3 of fha Bvainess pU71EtSpyER � . ,. . . �" :
�� aml Aofessiora Cod9,e�d my il[en79 n in R10 iqqp.q[Weffe�J. 5 PER SYSiEM ��FlNAI a .
Z a r. DATe � �D VALIDATION � �
! , lice�ne Nvmb ic.Cloa� � . , f a Q K �
FINAI O ,
; Con Oofe r��� . . BY L � {~j +
� d �
. � I qm exempl under$gc. . N
� 8.8P.C.fw�his reoson � . � Z ;
Plan che.ck fee
Data: . . PIUMBINC PERMIT IS$UING FEE E A O i
� Signature r_� ']�,� A
fOTAkfEE ,�Q !
Plon check ap .��n �.• • . • •5
� � MOME 04VNER-BUIID�'OECIARATION Nome ' � �!. . . . ��• •�:2.Jr t7 I
j ; I hereby aff�rm nc�t I am exemp�from�ha Ccnnocra a Umnse f ' - ' _
I lrnw for rhe follnwi�Q•ecsen($$ecyior.�{7.5,Business ond A� �� • • •5?..5 0 0
' Professiona Code): �City iel.No. - � �
❑ I,as owner of tha ro will do�he work and rhe � � " O 2 2 J—S 4
P P��1'• ,
, sfrerlura is nof inteadad m offered for wle(Section � i
7044,B�sineys ond Profession:Cada). � . � 3
CONSTRUCTION LENDING AGENCY � . . . . '
� I here6y affirm tha��hxe q a construcfion lendlm�agency fw - �
. the performence of�he work Fw which ihis permi�ia iaaued . . . . . ?
(Sec.3097.Civ.C.). -
. . �
Lender's Nume - �
lender's Addros� _ — - . . � . ' {
I cenify fiur I Mve rrod rhis applrcation and arote rhor the � ► . ,.
obave infornptivn is corred.I ogree b comply wiih all Counly
o.dinances ond Sta�e laws reguloting Pl�mbirg,and hereby
authorize re esentative oi�his Counry ro enror opon�he - � � � '
abore-men4 , p�o r lor inapection m. � �
SEE REVERSE POR EXPLANATORY tANGVACE _
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i rure of Permiaee - - . ,
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