HomeMy WebLinkAbout1652A (9) , WORKERS'COMPENSATIDNDECIARATION APPLICATION FOR PLUMBING PERMIT
I he.w6y offirm thol I hove a certifimte of mnseM ro self 20-0026 DPw e/e7 �
��iri,sura,or a certiticote of Workeri Compensation Insuronce, 76A667A
c;'a cerlified copy Ihareof(Set.3800,Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
P❑olicy No. Campany .
Cerfified copy is hereby furnished.
D . FOR APPLIGNT TO FILL IN(PRiNT OR TYPE) BU�IDING � �(� /� �y� j
� Cerlilied copy is filed with Ihe county bullding inspec• ADDRE55 0 V'9«��
fion deparlment. NUMBFR FIl(TURE OR ITEM � FEE
iouun
Dote AppliSonl WATERClOSFf NEARFST
� ' CERTIFICATE OF E1(EMCTIQN FROM WORKERS' BniN iUB �ROSS ST
• COMPENSATION INSURANCE OWNER •-�'�
(Thl���tlien n��d nef 6�eempl�Nd I!�h�work Inrolv�d by Srwwea i i0-"' .�
fhr p�nntf b for on�hundnd dellen(SI00)er 1���.) LnYATOkr ���
ADDQE �-.1
I cerlify rhot I�Ihe performonce of the work(or whlch rhis �
permlt le Iwued,I�holl not emplpy ony person tn ony monn SINK [I � 0 ' n TEL NO'� ' �
�o os fo becoms wbject fo the Wak �'Com nwnon L DISHWASNER
CONTRACTOW'
Dals" �pplitont CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, of r mokinq �hh Ceniflcote of SWIMMING POOL RECEVfOR
Eesmplion, you �ho�ld bseoms wb�eat �o Ihe Worken'
Comp�moNon proviflom o(Iha lobw Cods,you mu�r forth-. CiTY t[t.rro. .
wlfh COmply wifh W[h p�Ovldpns q ihb p�rmlt �holl bs �AWNSPRINKLERSYSiEM STATE LIC.
desmed revoked. W��ER HpntER UCENSF NO. (AAS$
LICENSED CONTRACTORS DECIARATtON oisraicr No. SSfo 6v
I hereby affirm ihol I am Ilten►ed und�r proviilom Of Chaplx 9 �3 SYSTE�.� - WTltTS � I O �3 .
(eemmeneinp wifh Sselion 7000)of DlvNlon�of the Bwinen OUTlETSOVER
end Profsuiom Cod�,end my liea��a I�I�full faca a�d sffae�, s veq SvSTEM FINA ,�1� VALIDATION n�',•,
Llesme Number Lla Clo�� DATE +- (�� p ,
U ,
FINAL
ConiroUor Pcie BY Q ,
❑ _ . . . !—
i om exempf under Sec. V
W
B,6P.C.fe�ihit rea�on a.'
Pian check fee , v�
Dote: � Z
. PLUMBING PERMIT ISSUING FEE S �
Sipnalure
TOTAL FEE
� ' � Plpn chetk opplicanf
SINGLE FAMILY
HOME ONMIER-BUIIDER DECtARATION Name � �
I hereby effirm�ha�I am eaempt from fhe Conhoctoi e License qdd:e:s
Law for the following rcoson(Settion 7031.5,Business ond
Professions CodeJ: City Tel.No.
❑ I,as owner of the property,will do the work and Ihe
strutlure is nat intended o�offered(o�wle (Sactlon . ,
70u,Business ond Profess�ons Code). �
CONSTRUCTION LENDING AGENCY " :� C)�a 2 A
I hereby nffirm thot theie is a tonstruction lending agency(or '
ihe performance of the work!ar which this permit is issued #• • • • •.S
($e[.3097.Civ.C.). I e •, �5 O
Lender's Name -
w • i � �17(��
lander's Address 0 9,� 9—8 a
I certify tho�I hove read fhis opplimtion and s�ate tho�Ihe ►
above information is correct.I agree to comply with all Couniy � � �
ordinonces and Slaie laws regulating Plumbing,and hereby
aulhorixe repre3enlotives of his Counly lo enfer upon Ihe �
ob e-menfi ed�property in6- t�ionpurpOses. � .
SEE REVERSE fOR EXPLANATORY LANGUAGE
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