HomeMy WebLinkAbout1441A WORKERS'COMPENSATION DECLARAT�ON � � �
��here6y of(irm thai I have a cenifica�e of consent�o sel( �bA��A APPLICATION FOR PLUMBING PERMIT 3�q
insure,or a ceni(ico�e oi Workers'Compensoiion Insuronce, CE B17(REV.10i81)
or o c=rtified copy Ihereof Set.3800,Lab.C.) COUN?Y OF LOS ANGELES � BUILDING AND SAFETY
Q�V No�mpany SYHrG �L�/Y/� �
Cerfified copy is here6y furnished.
� . FOR APPIICANT TO FlLL IN(PRINT OR NPE� BUILDING
Certified topy is filed wilh�he counry building inspec• AODRE55
tion deporlment. � NUMBER FIXTUREORITEM � FEE
�n..d' J-/17 IOCAIITY J�
pole��=�Appliconl ��°� �L�r� WATE4CLOSET NEA4EST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH tue CROSS ST. � p �
� COMPENSATION INSURANCE � SHOwER OWNER O�, e �
� (This�edlon nsad not hs compl�bd if the work inrolved b� MA(
fhs p��nl/i�#er ons hundrcd dollay(5100)or Iefs.) IAVATORV ADDRFS$ i� ��
I ceni{y thot in the performance oi Ihe work for which Ihis
permif is iss�ed,I shoil not employ ony person in ony ma�ner SINK Y a� CITV Q / TEL.NO.
so os�o bacome subjeU io�he Workers'Compenso�ion laws. d
. DISHWASHFR CONTRACTOR
D��r. Applicant CIOTHES WASHER �'
tf-E TO APPLfCANT: If, oiter moking Ihis Cer�ificote of AD�RE55
l._�plio�, yov shooid become subject to Ihe Worke�s' SWIMMiNGPOOtRE�EPTOR a7
Compensation provisions oi the lobor Code,yau musf farlh- �AWN SPRINKIER SYSTEM CITY O��T �� �� ��z
wi�h comply with such provisions or �his permit shall be� SiniE �i�, /
deemedrevoked. - WATERHEATER � LtCEN5EN0 � CLA55 ��U`
LICENSED CONTRACTORS DECLARATION DISTRICT NO. W?OCESSED BY
1 hereby affirm iMt I arn licensed undei provisions of CFwptar 9 �+S SYSiEM OUTLETS ,
(commencing wi�h ScUion 7000)of Division 3 of�he Bosiness � WilEi50vER � �- :
, ond 7ro�ass�ons Code,�ond my license is in Full force and eHecf. 5 PER SYSTEM FINAL
�I��G �t3 G � DATE `��Ij� VAUDA710N a�,
l�cense Number� L�c.Closs
./ �+ `J FINAI �
Con�rac�or,�'� ��/� Daie 7���D7 BY V�
❑ �� �1441A �
I am exempl under Se[. O
8.8P.C.for rhis reoson �• • • • •5 V �
Plan check fee �,
oa�e� , � . .2 2 5 Q u>
PLUMB�NG PERMIT ISSUING FEE E -
Signalure � G r
z•
TOTAL FEE �Q - � ° •2 7.�O
. . � Plan theck applitant � �9�� v—8 7
SINGtE fAMIIY '
HOME OWNER•BUILDER DECLARATION Name
�reby affirm�ho�I am exemp�from�he Contractor's License '
�n,,i..,rt,e(�tt�..,�..y._..__. (c.:!ier,?,,,,. . ,,,�n�»Gr.. Address
.Pro(essions Code): - ���
V` J V Y Tel.No.
❑� I,as owner of the proper�y,will do fhe work ond tbe - �
shaclure is nof iNended o�offered!or sole (SeUion � ►
70e4,Business and 7roiessionz Code). � .
CONSTRUCTION IENDING AGENCY �
I hereby offirm thot lhere is o tonslruclion lending ogancy for
fhe performance of the work ior which this permif is issued
(Sec.3047,Civ.C.�. �
Lender's Name �
Lender's Address
I ce�tiiy�hot I hove read this appiimiion and sto�e�hat ihe �
obove informotion is correct.1 agree io comply wi7h oll County - .
ordinances ond Stote lowz regulo�ing Plumbing,and hereby .
outhorite representotives of�his Coun�y�o en�er�pon the
o6ove- entioned pro erty{pr inspedion porposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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