HomeMy WebLinkAbout1345A . WORKERS'COMPENSATION DECtARATION APPLICATION FOR PLUMBING PERMIT {� .,
I he�eby affirm thal I hove a certificole o(consent to self �ap,y��q I�
insure,or a cerfiiimte af Workers'Compensation InSuronce, [E gp(REV,10/81) . _ , . .
or a cerrified copy rhe�eof(Sec.3800,lab.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
POolicy No. Company . -
Certifiad copy is hereby furnished.
OFOR APPLICANT 70 FILL IN(PRINT OR TYPE) BURDING 'r �
Certl(ied copy is(�led with the co�nty b�ilding inspec- ADDRESS �7/71 8 Bl y p
tion depoilmenl. . NUMBER FIXTURE OR ITEM � FEE � �
�) ��.��TY � b N
Dole Applicanf WATERCL05E7 •V NFAREST
� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CRO55 Si.
COMPENSATION INSURANCE � DW�R� 'l �L O /L
(This��dlon n��d not b�compl�t�d 1!th�worlc Inrolv�d by SHOwER , .
fh� �rmN Is lor on�hundr�d dollan SIOD or I�ss. M'�'�� �r,� /�yLp�,/�,'y
P I I I f LAVATORY G� qpp��
-I certify�hat in the performonce of�he work for which this Q �y
permi�is issued,I aholl not employ any perso�in any man�er � $INK . � CIN j,�Q�J AX��T l�.�rv�. �-S9�/
:a as to bemme subjecl to the Workers'Compensotion Laws. DISHWASHER . . ��NTRptt�'[+�/ �E� A/"
J d OGr
Dole�^��-��Appliconl CIOTHE5WA5HER ADDRESS ��d� E(7 f �
NOTICE TO APP�ICANT: If, after making �his C icote oi SWIMMINGPOOIRECEPfOR
Evemp�ion, you ahould become subject fo the Workers' f'
Compensotion provisions of the Labor Code,you mual iorth- � CIN �X�� �C� TEL.
wi�h com I '�h such rovisions•or �his e�mit sholl be �AN/N SPRINKLER SYS7EM '
p Y p p Sin ^ C�/ O uC. ,7 J
deemed revoked. � - . � � WATER HEATER ������J� 6/ / CLASS �4 �p
� LICENSED CONTRACTORS DECLARATION DISTRICT NO. Pf70CE55ED BV
I heraby aff'rrm thal I am litensed under povisions of Chapter 9 GAS SYSTEM- OUTLETS �O _
(commencing wirh SeUion 7000)of Division 3 of the Business OUilE750VER
ond Professions Code,and my litense is in full fwce ond effect. , 5 PER SY57EM FINAL � �
!) Q G / ��� VALI ATION
license Number��'1���'/ lic.Closs r^ �S � ���p DATE G� a'
�� ����>JYS z � BY�Z �
�a�,�a��o.S'E'Rvi��pleG�,e -��—p �p � a
0 0
I om exempt under Set. y
B.BP.C.fo�ihis�eason Q�M ��!'s W'
re: Plon check fee ► :'=1 3 4 5 A N
PLl/MBING PERMIT ISSUING FEE S f O Z
$ianon�rn'��� � �J• • e s •5
TOTAL FEE
. . . . � Plan check applicam . J .a e 5 a�j Q
$INGLE FAMIIY
HOME OWNFR-BUIIDER DECIARATION Name � � � ' °���O c:
I hereby offirm fhot I om e.empt from Ihe Coniroctor's License q��ess
�nw r,,.rtie�„n,,,.,�„�. „rce.r,.,,�m�S P�n ..a 0$2 7—8 6
_A,�o..,_ .._...__.._. _ �..e.<..
Professions Code): D City iel.No.
❑ I,as owner of Ihe property,will do the work ond�he
slruclure is not inlended or oHered for sale (Setlion �
70dd,Business ond Prafessions Code).
CONSTRUCTION LENDING AGENCY . . _ _ _ .
I hereby nfiirm ihal lhere is a tonsh�ction lending agency for .
�he performance of ihe wark for which this permit is issoed _ _ _ . _ . __ , ,
(Sec.3097,Civ.C.).
Lender's Name �
lender's Address '
I cernfy�hot 1 have�ead�his opplfcation ond srote that the ,
above informotion is correcL I oq�ee�o camply with oll Coaniy � ' �
ardinonce:ond S�ate lows regula�ing Plumbing,ond hereby
au�horize representatives of this Couniy to enrer upon ihe � � � � � � �
ahove-mentioned property for inspection pur�oses.
� SEE REVERSE FOR EXPIANATORY LANGUAGE
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Signarore o�miifee Daie - �- � -� � �
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