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HomeMy WebLinkAbout0926A WORKERS'COMPENSATIONDKLARATION � APPLICATION FQR PLUMBING PERMIT � I hereby,off�rm rho�I have a certificore of consen�to self 7gA687A insure,or a cerrifico�e of Workers'Compensotion Insuronce, CE 817�REV.9/88) � ' '- , . � �� . . . , .. . . . --. . ` or o ceri�i�ie�d Qco�pyQ tch�e�re�oy(,�(]Sec.38o�D,l�ab.C.� / COUNTY OF ld3 ANGELES OEPT. OF PUBLIC.WOR i P�oi�ity Na(1_LL�?rL.Z_�C6mpony ♦Yl�'P_ �/j/JA . , . . . ���. #/i.�. - �1 � Cenified copy�s hereby fumished.� - Y �� � . FOR APPLICANT TO Hll IN(PRINT OR NPEI ���� 3 �� _ Cerrified copy is fi�ed with ihe counry buildinp inspec- � tion deportmenL . NUMBER � FIMURE OR ITfM � F� tOCAUTY � � � .']��,, {��]� warta nosei � 1 �Do�e��Appli4ant � .. . 00 NEAREST - � ' �CERTIFICATE Of EXEMPf10N FROM WORKERS' . . eATH TUB. . O D CROSS 5T. - ' � � COMPENSATION INSURANCE � � S��R 4O OWNER . � " � . . i�� � . - . . (Thi�s�ctlon nNd nof b�eompl�Nd if fh�work Imolwd b� ��� . . , ... ' th�pnmit i�for on�hundr�d dollon(5100)�or I�sf.) uVniORY A��5,5 . 1 cenify�hot in the periormonce of�he wo�k for which�his ' permil is iseued,I sholl nof employ any person io ony monner StNK! p� CITY C � . �p"'r- � . � so os�o become subjecl�o the Wo�keri Compeowtion Laws. - � �/ . . . ��/ OISHWASNER . 0� CONTRACiOR . .. . . _ '� 1 � t epplitonl CLOTHES WASHER - � � qppRE55 ' ' �TICE TO APPIICANT: If, ofror making rhis Certificate af d� 5 - � - SWIAAMING POOL RECEVTOR E.emp�ion, you should become� wbject ro �he Wwkers' �iTM I �Compensotion proviaons of�he Labor Code,yoo mvst Forih- �qWN SPRINN4ER SY51EM pn G OUC' .' -' `3 " � wi�h compiy wiih such provisions or this permit shall be SiATE IIC. . deemed revoked.'� - � WATER HEATER D LKENSE NO. � 3O 3 ClASS�� � �UCENSED CONTBACTORS DECLARA710N� ' � �tSTRKT NO. PROGESSED DY I hereby affirm rho�I am licensed undx provisiom of Chapter 9 GAS SYSTEM � W11ET5 �� _ i (commancinp wi�h Section 70p0)of Division 3 of�he Businexi . OUttEt50VER . . . �a �O �.'� and Professfons Code,ond my Iicense is in f�11 forcs ond effect. 5 rFa SvSTEM FINAI yALIDATION O, License Num6er �'3�� Uc.Gloss�� Cj DATE S'f- . V ' f�/� Q�� -�� �� FlNAI � Comroc�or.�iSC�t C� LLI2.;�Daro.;�.LLL_ �� BY � - �,!, � ❑ I am enempt under Sea �� . . . . . . . - W . 0. 8.8P.C.for this reoson � , � Plan check fee ? j Dnte: p�UM81NG PERMIi ISSU�NG FEE f . s9�awre ?Q 9 2 6 A .. � � TOTAI FEE d SD �, • • . e$ , . ' .. . Plon chack opPlicont i s�Nc�e Fan�i�v I • 1 0�5 0 �.� HOME OWNER-BUILDER DECLARATION �� Nome ' � � �� � � . � _._ s.�o , O�,5 D U , ' I beraby offirm thv�I am exempt from�be Conhacror'a Liesnae pddreas - � - - � - � � � � . Low for�he followinp rea�on(Sectien 7031.5,Bvsinns and 0 t�,L� -8 7 ' Professions CodeJ: - . . . City � � Tel.No. � �. ❑ I,os owner of fhe properly,will do 7hs wwk ond the � � �► � strueture is noe�nisnded or offsred for wie(See�ion � . � � - � � . � � - � ', 7W4,Busineu and Profesaiom Code). � ' . � � GONSiRUCTION LENDING AGENCY � � � � -� - � ' - � �-�� �- � � � � � � � � � I heroby afiirm fhar fhere is o conshucrion ImdinQ oQsncy for . � ihs performance of�M work for which tAi�permil is issued ' - � - � � � ' - � ' (Sec.3097,Civ.C.). � � . Lender's Name . .�. . . .. . . . . . lender i Add.ess . . .. ... .. . � . . � I I rortify�hal I hove rsad ihit application ond srota thof ihe . . . �. . . . . .. � .. . . . ! above i rmation is caroct.I aqrae ro comply wi�h oll County I ordina ce und Sto�e I a ropoiaiinq Pl�mbinp,ond hereby _ _ � ► . �ii ourhor e r esen�o�i s of� s CouMy fo enter upon ihe � � �� � � - � � - � � � obove n o ed rty f nspec�ion purpos�s. SEE REVERSE FOR EXPLANATONY IANGVAGE � � � �qnature of Permittae Dor� � . , �, ��.` . , �... . 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