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HomeMy WebLinkAbout1233A (9) � WORKERS'COMPENSATlONDECLARATION APPLI�CATION FOR PLUMBING PERMl�� � � �� + � �, I he�eby+bilvm ihat I hove a ce.rtificate of consenf to self��� 20-0026 DPW 6/87 . . . � � � r'I 1 � � inwre,or a certi4icnte of Work rs'Compensation Insuronce,..�'. 76AG67A � L! � . or a�certif�ed mpy 7tfiereof Sec 3800,�.ab.C.) �� COUNTY OF LOS ANGELES � DEPT.�OF PU$LIC WORKS . � . , ' ' � ' P❑oll[y No.�7�C m any_ } � . � . �' ... � .. ' '�. � � Ccrtified aopy is hereby furnished. RuuDwG Q� ��q��y�y (�^P FON Af•Pi.ICANT TO FILI IFV(PR!N1 OR iYPE) ADDRFSS l(J 7 S' �7�'T��'�',,v''� "'!tl• � '. ` �Certified copy�s filed vitH the county building inspeo- -- '- , � � :�.IiOn deparl ent.ay/C NUPhBI:R FIXTUHE OR ITEM C4 _FFF. ��,',*���9 d[J _ J LOCALITV /QI�� f ,�r• �.�Dole �_ Applicant� — ___' WqTF.RCLOSEY"" _'_"_" _'_ ' ___�.4.. ' NEAREST _ ... RATIi TI16 CRO55 ST. � CFRTIF AlE OF EXEMPTIO FROM WORKERS' �� —� � I COMPENSATION I � URANCE ---` .... ..----' --- -'- O�VN[N � ' � .. Sh;OWER (This secffon need nof be completed if the work involved by MAIL jU;j�y .�J"�� � �ehe permie is for one hundrod dollars(5100)or less.) LAVAiURV nooRr55 �I S, _ �� . , � � � 1 cerliSy lhat in the performance of Ihe work ior which this -----�--"---""-' '— '- — : perm��is issued,I shall not employ any�erson in�ny rnanner _� S�N� _ ��TY l��i.l+'�.�+� ��� TEL.N0.2/.7�'" b � �'w�F1f r�� .�so as to become subject to the Workers'Com�pnsption laws. DISHWASHI:R /� � na � � . . .-_'— '__"_ .—.... CONikACTOR � NR�W/�E Cia'�IS , Date� Applicnnt CIO1Hf5WASH£H pDDRE55 W...._. V�//liL'� �� . . NOTICE TO APPLICANT: If, ofePr mpking �his Certificate of SVJIlAMINC:POOLRECEPTON --�—���- �` ' � . Exempfion, you should become s�bject Io the Warkers' __ __ __ CI'1Y�-������ T[l.NO.� � � �Compensation provisions of Ihe Gabor Cocle,you must for7h �AWN SPKINKlER SYSiEM � with comply with such provisians or this permil shall be STATE (� ` LIC. , deemed revoked. WATER Hf:ATER �"''� LICENSE I�O. l�, YJ CLA55 � , � LICkNSED CONTRACTORS DECLARATION - — �� Di57RICt NO. PROCESSED BV , I hereby offirm tFat I am licensed under provisiuns of Chopter 9 �AS SYSTEM � OUTLEiS � . � ; (commencing with Sec�ion 700U)of Division 3 of!he Business Out�ET50VER ' � ;� �.and Professions Code,and my license is in fuEl force nnd effect. 5 PER SvSienn fINAL f ALIDATION �L,, `I �L_ -�SVfNII. !f DATE ./ I! (�•,. CJt � License Numb Lic.Closs_ �- � , ,. — _ _ 7. � � FINAL — . Con�ractor BY � � ❑ I am empt under Se _. �� a`�' � 6.8P.C.for this reason -- -- � � Plan check fee _ �: � Date: _— . . �7 PLUMBING PERMIT ISSUING FEE S , � '�(J � Signature_. --.-.-'---- TOTAL FEE ��� �.` I (:,`�.�'', . . ��� _ — ( . � Plan check applicant �^ � -' •' ,., � �. SINGLE FAM1•IILY � � HOME OWNER-BUILDER DECLARATION ' Nome __ ___ � � u u(;L:..°i�; .. � � i F,o.o4,y�ff�..�,�V,��i nm w.Amnt fmm rhn('nmmrtnr'x I ic�nsr �. (qddress � .;-�,-. .Law for the following reason(Section 7031.5,8usiness and � � C 4;:: �Professiorts Code): , Ciiy ?el.No. I � �---_ I,os owner of the property,will do ihe work and the �E��C S `rt(S �, structure is na intended or offered for safe(Section � . � 7044,Business ond Professians Code). � ' � � CONSTRUCTION L[NDING AGENCY � � ' I hereby nfflrm tha�ihere is n<onstrvr.tion le�d�ny agencyfo� ' �'�he performance of the work for which this permir is issued � , �(Sec 3097,Civ.C.). -� Lender's Nome_-- --.---- � Lerider's Address_ �I certify�hol I have read this upplicalion nnd sl�ie thnt th� � � � '��nbove informotiun is cor�ed.I agree to comoly with all Counly � '�ordinonces and Slale lows reg�la�ln9 Vli�mbi�,g,and 4�ereby � autho�ize ienre'sentative.s of fhis Counly�o rnier opon�the , . °above- � lioned�pr pe��y for inspection purpose.s. 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