HomeMy WebLinkAbout0952A (5) � WORKERS'COMPENSATION DECL4RATION ' � APPLICATION FOR PLUMBING PERMIT � ;
I hereby affirm tho�I have a cer�ificota of consent to seN �� 76A6y�q .
insura,or a certificata of Warken'Compenwtion Insurance, CE Bi7(REV.IOi81) i
a cenificd copy thmeof rsec.3800,lab.C.) i COUNTY OF LOS ANGELES BUILOING AND SAFETY '
4.�L' S//s� 3 G ,A
i
PDol�cy No. ,Company��si��- .�a , . - ' �
Ce���t�ed copy is hereby furniyhed. '
QFOR APPIICANT TO fILL IN(PRINT OR TYPE) BV���NG �
Certifi4d copy is filed with rhe mun�y building inspec• A��u
Kon depaRmertl. � NUMBEF FI%lURE OR fTEM � FEE �
, ' LO[ALIIY
WATER QOSET �
te AppliSanl � - �O NEARE57 � i
� CERTIFICqiE OF EXEMPf10N FROM WORKERS' 9niH 7U8 CRO55 5T. '
COMPENSATION INSURANCE ��R pwNER � �
(Thls s�Nlon nwd nof ba complN�d tF ih�vrork�nvolwd br
the p�rmlt It for on�bundrod dollats(S10D)or I�t�•) lqvntORY QQ p�� .S� !
I cenify rha�in�he pertormancro of�he work for which this 1 '
� permif ia issued,I iFmll rro�emP�oy any person�in ony manner 51� � 10 � � �•�. �
- so os�o bacome subjea ro fhe Wor4ers'Compansafion Lowa. � !
. . DISHWAS R COMRA[fOR
. pofe � � �pplicanl UATMES WASHER � / 1
NOTIC�i0 APPLICANT: tf, ofrer moking rhie Cenifiea�e of SW�������� � i
ExempNon, you �hould 6ecome subjed ro ihe Workers' G7v '
Compenwtion provisiom of Ihe Labor Code,you must forih- �qyyN gpRlryKIER SvSTFM -'
with comply with auch porisions w this permit ahall be STAtE ;
deemed rovoked. WAtER MEA7ER ��� �u f
UCFNSEp CON►RACTORS DEQARAt10N DISTRKT NO. � BV
. I here6y affirtn thol l om IitenseQ unda povisiom Of Chapter 9 � GASSYSTE/d WTIfTS
(rnmmencirp with SeNian 7000)oi Dirision 3 of�he B�siness pUl1EtSOVER . } '
�d Rofenions Coda.and my liceme is in f�ll fqce a effett. S PER SYSiFM FWpy d �
oA� .�ay��/ VAUDATION ' � �
Litense Num � ic.Cipsi CC i
FINAL O i
R�'w���le I � 6Y rh,CC< � ;
❑ I am eaempt uidar Sec. . � d ;
H :
0.8P.C.for this reoaon z �
Plon check fee � �
�re: PIUMBING PERMIT IS$UING FEE S IO � � � - �
Signalura �
rorru r�e "s� �0 9�2 A �
. . � Plan cbeck opplicont �
$INGLE FAMILV � . #� � • • �J�
HOhAE OWNER-6UIlDER DECIARATION Name ' �
I herelly offi�m If�pf I Om OaOmp�from fh9 CO�hpclp s litlM9 �� -� ••5 4.5 0
Law for tha following reoson�Sechon 7u;1L5,yuafnesa and � . . ..
Rofeasions Code): City . Tel.No. • • `S��Q�' -
❑ 1,m owner oi the propeny,will do tha work ond�he O��.� O'�Pi�1 '
shucture ia rro�iMended or offprod fw wb(Sec�ion � � . ' i
70M,Bu:iness ond Wofessions Code). � � � . ;
CANSiRUCT10N 1EN01NG AGENCV . . - . .. � . . �
1 hereby offirm�hol tF�ere is o conshucFion lending ogenty for . �
the perfmmance of fhe work for whicb 16is permit is issuad . . . .
(Sec.3097,Civ.C.).
j
Lender's Noma � �
Lender's Addren �
I ce�tify ihat I ha�e read th�s opplicotion ond s�ate ehot the ►
a �e information i carecL I ogree fo comply witM1 all Counly.
� ina�tes a � e laws reguloting Plumbing,ond hercby
Ih re lotiv9s oi this County lo enter upon the '
e- e properly fw inapection pu oces.�
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