HomeMy WebLinkAbout1745A (17) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT � � i
I hereby affirm�ho� I hava a certificate af consen�io xlf �bp6y7q
insure,or o certificate of Workers'Compensallon Insuranca, CE g17(REV.10iB1� ��`�f j
or o cerfilied copy fhereof(Sec.3800,La6.C.) Cp�1ryTy OF LOS ANGELES BUILDING AND SAFETY 1 �
a�Y��o�^Pa^Y Frnmont� TnAomnity . Ot
Certlfied copy is heroby fvrninhed. BURDING
� Carnfied copy ia Nled w��h�he counry bu' ing impec• �AGPl1GWT TO FHl IN(PItMT OR TVPF) A�� ;
tion departmvn�. NUMBER FU(TURE OR ITEM � F� LOCA4TY �
OOfe �I�S AppliSonl � WA7ER C105ET d ` NFAREST. . ��
CERTIFICATE OF E%EMP(ION FKOM WORKERS' � BnTH 7UB �
� � CR053 ST. 3
COMPENSATION INSURANCE SHOWER OWNER ;
(Thl��M�on nood notbe eompbl�d 1►Th�work Invotved by
1ho pvrmlt b for on�hundhd doliun(SI00)or bsa.� 3 �tyqipRv ��� ,
ADDRESS
1 certify ihat�n�he parformance oi�Ae work for which rh�s . ,
pprmif is Issued,I ahall no�emptpy pny person in Qey rtqnner SINK Ciri iH.
ao ca�o berome wbjea to the Worke�s'Compensation 1aws. o�waSHER !
/ cor�rw�aat i
�o�a °PPIicaM � ( CtOT1fE5 WASMER • � � :
� �'^ CE TO APPIICANT: If, qfter rtMking lhis CerNficele of A�� 1 �.� _ �
f �prion, you should betome subject ro �he Wbrkni ��������
�c,,,,6penso�ien prpvisions of the la6a Cade,you mus�forth- drv �Et.NO. �
tAWN SPRINKtER SYSTEM
with tomPly wNh suCh prpvi`�oM or this pennil shnll be ��,,�. 336428 - "c. C-36 �
dRemed rBwked. WAIER HEAYER ��+`
UCENSED CONTRpCTpRS DEC}ARAi1QN _ pSiRiCi taq rROCESSED BY -'.
I herobY affirm�Iw11 ao licensod urder RpvisiD*+s of ChO�1Mr 9 GASSYSiFM WilET3 �d ,
(commerrcing wiM Sedion 700p)aF pivision 3 of tha 9usiness puitFiS pyEp y' 1
and Aofestiqnt Codp,a�mY��CnsO is in hill fvrce anQ.effect. . S PEB 51'S1E1M FINpL - . � �
oA� l 1��� S� v uoanoN a ;
Li�ense Number��_Lit.Closa.�_.. . m ?
c�,�«w. ACR Plwnbin�oare G/19/85 Bvn� o ;
❑ �am esempt under Sec. �'� 7 Q,$f� N ,
o. !
B.BP.C.for this recson ' � z ;
Plon check fee ► u• • • •5 �
�re:
5,�,�e � PLUMBING PERMIT ISSUING ffE 3 p I.• •8 3 5 0 �
TOTAL FEE a e(1 Fj j Q c�
%an check appliwnt � �
swct�FnMav ING, INC. - 0 7,2 9-8..
HOME OWNER•BUILDER DEGARATION Name
\ }eby offirm that I om eaempr from the Contrallor's licensa V2. . � !
1 .�tor ihe following reaton(SeUion 7031.5,8usiness and Addrees �
Frofeaions Cade): Ciry � iel.N
❑ I,as owner of rhe property,wiN do rhe work o��he . . �
sfructure is not inlended or offerad for sole($eclion i
70dd,Business and Rofessions Code). i
CONSTRUCTION IFNOING AGENCY � �
I hereby affirm�hat ihere is o construdion lending agency for - ' �
1he performance of Ihe work for which thi�pe�mil is issued �
�Set.3097.Civ.C.�. . �
Lender i Name �
lender's Addres: � '
I cerlify thol I hove reod ihia ppplicolion ond s�are tha�the ► �
a6ove informo�ion is carect.I agree to comply wilh oll Counly 1
oidinoncea ond Sb�e laws reguloeing Plumbing,ond hereby
ault�orize reprefeNalives of thls Coumy�o emer upon rhe � �
obove-me�lionpd p� Ny for ins ction purposes. . ;
SEE REVERSE FOR EXPLANATORY LANGUAGE
R.C.R. Bv�QAa�.��J19/85 j
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