HomeMy WebLinkAbout0853A (4) WORKERS'COM7ENSATIONDECIARATION APPLICATION FOR PLUMBING PERMIT {� �
I hereby atiirm that I have a certificote oi conseN�o self �pqyb�q
insore,or o ce�iifimte of Workers'Compensation Insurance, �E B17(REV.10i81� - ' LI
or o cerrif�ed copy rhereof ISec.3800,�ob.C.) . COUNIY OP LOS ANGELES BUILDING AND SAFETY
P❑olicy No. Company ' '
Cer�ified copy iy hereby furnished.
❑ fORAPPIICANTTOFIIIIN(PRINTORTVGE) BUILDING h,,
Cerliliad copy is filed with�he counly building inspec- ADDRE55 � N,�TN'�.�Q� �✓�4
tiondeparfinent. NUMBER FI7(TUREORITEM @ FEE ��q�ITY'�fii,b�� 8�Z
WATER ClOSET
Date Applitant CRO555T. 5 LV� �7L�
CERTIFICATE OF EXEMPTION FROM WORKERS' Bniti TUB
COMPENSATION INSURANCE OwNFR �'� (�', ��)}�j,/Z,�
(Thi�s�eflon n��d nof b�tomplN�d tf ths work inrolr�d 6y SHOWER
Ih�p�rml�b lo�ona hundr�d dollan(S100)or la�s.) tAVATORY ��� �I�,
I cerlify thol'n the performonce of the work for which this ADDRE55 �.� N� �
permit is issued,I 5holl nof employ ony person in any manner SINK CIN �0�� 8 M TEt.NO.' Q6o 3
so os to bacome wbjed to�he Workers'Compemoii) L �T��� .1
\�� [ DISHWASHER COMRACTOR 5 AgdVG O��IV
.lDate '� � pplicaALe=�"�✓• CLOTHES WASHER ADDRE55
� NOTICE O AP LICANT: If, afler making this Certificate of SwiMMiNG POOI RECEPTOR
E:emp�ion, you should become�subjed to the Workers' Citt TEL.NO.
Compensotion provisio�a of Iha Labor Code,you must foffh- �qWN SPRINKLER SYSTEM
wilh comply wHh such p�ovisions or fhln parmit shall ba STarE uC.
deemed revoked. . WATER HEATER LICENSE NO. CLA55
. IICENSED CONTRACTORS DECLARATION DiSTR�CT rd0. PROCE55E�BY
�I hereby oH'vm 1ho1 I am licensed under provisions of Chopter 9 GAS SYSTEM OUTLETS • v
(commencing with$etlion 7000)of Division 3 of�he B�siness OUTIETSOVFR
and Vrofessions Cade,and my ticense Is in full force orid effec�. 5 aeR 5vsreen FINAL�i!/,p Q ALIDATION
- DAiE �C� O(� a,
Licanse Number Lit.Closs
FINAL�y��y7.1 V
Contractor Dafe BY .,r/// �/7
�
0 0
I om esempt under Sec.
B.BP.C.for this reoson V
- Plan che<k fee a
Date: p��MBING PERMIT ISSUING FEE E U � Z
Signofure —
10TAL FEE (� S :Q$�3�
" . Plan check appliconr � n a e e a a 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name _ � I • • � �S O.
I hereby oflirm that I am exempt from�he Conhacror's license Address
Lew(or thr followin�rnmm�fSorHon 7031.5, Auci�P.c nod � ' e a s 1 /_i(1 T
Prof sions CodeJ: City Tel.Na. �
I,as owne�of the properry,will do ihe work and the �
0$18-87
structure is no�intended or offered tor sale($edion ,
7044,Business and Professions Code). � - � - '
CONSTRUCTION LENDING AGENCY . ,, ., ,. , , _ _ _ ____ _ . ., ,
I hereby nffirm Ihat there is a mnstruciion lending agency for �
�he performance of ihe work ior which ihis peimit is issued . . ..
(Sec.3097.Civ.C.�. . . - . . -- --
Lender's Name'
lender's Address � � � � - -
I certify Ihat I hove read�his application and s�ate that ihe ,
above informotion is correcL 1 agree ro comply wi�h oll Couniy � " � � '- --- -
ordinonces and Sla�e lows regulating Plumbing,and hereby R
au�horize representatives of this Coun�y ro emer upon the . � - � -
above-menfioned propert for inspec�ion pwposes. (-- -� -
SEE REVERSE FOR EXPLANATORY LANGUAGE �
��G. q r7 $7 �
SignoWre oi Permittee Dale - � I
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