HomeMy WebLinkAbout1417A (11) �
WCtiRKERS'COMPENSATION DEGLARATION qppLICATION.FOR PLUMBING PERMIT � � �
I herq�o1n'rm�hai I have a certlficore of consenl to self �bpyy�q � �
inm 1;•,or'o ce�lificote of Workeri Compensolion Insurance, CE B17(REv.16/81�
or a ce�i�eod co8y ih epf,�(Sec.3800,lob.�� COUNTY OF LOS ANGELES BUILDING AND SAFETY . �
O �7
P❑olity No. ompony � ` ._ ,
Certified copy�s hereby(vrnished. BunoiNG
FOR APPLICANT TO FILt IN(PRINT OR TYPEJ ADDRES$ �
�ertified copy is filed wiih ihe tounly building inspec- NUMBER flxtUREORiTEM (D FEE
lion department. - IOCAIITY �
n I WATER CLOSET Q"�J �p
Do�eT�� —�7 ApplitantM�I �'1�C�iYI . Y � � NEAREST �
CERTIFICATE OF EXEMPTION FROM N�ORKERS' � BATH TUB ' r (l�J ��ST' N �
COMPENSATION INSURANCE OwNFR � � R 0
(This s�cfien nNd no1 b�compl�t�d II tha work Inrelv�d b� SHOwER �" e�
fh�p�rrtd�It For ono hundnd dollan(5100)or bss.) lAVA70RY ApDRE55 �C� S y ' pYJ D D
1 ce.rrify that in ifie performonce of�he work for which�his J61� / I
permit is issuad,1 sholl not employ any perwn in any rtwnner � SiNK -u CIN� � �b TEL NO. jy �p p
so as�o become subjec��o ihe Workari Compensolion laws. //_ DISHWASHER � 6 Q Q
r) CONTRACTOR
Dote epplicant- - CIOTHES WASNER
NOiICF TO APPLICANT: I(, afier making fhis Cerlificote of ADDRESS {�,�.
Ezemp�ion, you should become subjetl to the Wo�keri Sw�r�urHNGPOOIRFCEefOR 1 ,
Compensation provisio�s of fhe Lobor Code,yw must forth- LAwN SpRin�KIER SVSTFM ��tY N TEL 1 O O
with comply with s�ch provisions or thls permit shall be SiATE liC.
deemed revoked. . WATER HEATER LKENSE NO.s� ClASS
LICENSED CONTRACTORS DECLARATION I DISiRICT NO. PROCESSE�BY
I hereby offirm thot I am li[enspd under provisions of Chap�er 9 GASSYSTEM OUTLETS t� �n
(commencing wi�h Section 7000)of Division 3 0l the Business pU7lET50vER j� �
� ond Rofessions Cade,ond my license is in full force and effect. 5 aER SVSTEm FINAI �!�� VALIDATION
� � �, �yI - DATE —..�r p�,,,��..
license Number�Q �G / Lic.Class L.,L O
/_ p-7 FiNa< <1 4 1.7 A c�.
Conlrador l��A/ (`��l�LL� Daie 9�9�o/ . . BY �• � • • •5
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❑ I om exempt under Sec. � � •9 2 2 5 0 U
8.8P.C.for this reason PIOn Ch2Ck fBB , • ���7_5 0� d�
1e� PLUM6ING PERMIT ISSUING FEE S �(� 0 . G 9,C 9—8 7 ��
$ig�at�re 4�� �� t
TOTAL FEE �
- Plon chetk opp�imnt � -
SINGLE FAMIIY
HOME OWNER-BUILDER DECLARATION Name .
I hareby oHirm thof I om erempl f�om 1he ConlraUor's license ,qddress
law for ihe foliowing reoaon(SeU�on i031.5, Business and .
Drafessions Code): ���y Tel.No.
❑ �,as owner of ihe properly,will do fhe work ond the
shucture is not in�ended o�oifered for sole(Settion � ►
70A4,6usiness ond Proiessions Code). .
tONSTRUCTION IENDING AGENCY � �
�he�eby�Nirm thal ihere is a conslruclion lending agency for . �
the performance o(the work for which this permit is issued
(Sat.30v7,Civ.C.). -
lender's Name
Lender's Address � �
I cerliiy thot I hove reod lhis opplicotion and slate ihat Ihe , -
obove information is mrrecl.I aqree lo mmply wilh all County � -
ordinances and Stole lows reguloting Plumbing,and hereby .
au�horize representa�ives of ihis Counly to en�er upon the - � � � � -
obove-mentioned p�ope�ty(o�in5pec�ion purposes.
j —8� SEE REVERSE FOR EXPIANATORV LANGUAGE
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