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HomeMy WebLinkAbout1237A ' R'ORKERS'COA4PENSATIONDECLARATION �sassoa �� � , , . _��:--- .�_. . �--- - ---.:�:---- -r----__.._ __,� �_.._,._.., nP�i o('��ric�ni F(�R PLUMBIIVG PERM1�" � ; : .:�.�.,, ::,:,�::: :::�: ; :,�.� � ��:.:::�s:� ::: ��:::�.: :���:. _}�:::�-....; - -- = r--- - - -—- - - — - - - - Insure,or a certificate oP lVorkers'Compensation Insurxnce,or _ . � . p a ccrtified cnpy thereof(Sec.3800,Lah.C.) - i ���h� ���/. �.-��� C�UNTY�F LOS ANGELES BUI LDING kND SAFETY � Yolicy pany � , f � � Ce[Yified coOY�s hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /� .. ` fVUMBER FI%TURE OR ITEM • FEE ADDRESS �C�Cf7� � -, p�LEJ �fA�I�. � Certified copy is filed with th� county buil p ' �%y 7 �1 j/ ' �tdepart .� . '� � s e n _T.R______._. LOCALiTY � ��L.}7%�/W (T! ,� .. �r N:P..E CLOSET -� llate � r- AppliCant � �+ " f — NEAREST � � 6ATHTUB CROSSST. � �:� ,��` CERT7k'IC�TH OF'F.XE:MPT70N b'AOM WpRKER�' - ' COMV�NSA'f10NINSUKANCF. � SHOWER OWNER a� ____ : �� MAIL � (This section need not be completed if the woak involved ' _ �avaYCRv i �aooREss � � . . -----__.._ � � by the permif is fc�r one h�ndred doliars (5700) oi teas.} - swK ��1v 're�.No. � - ' ' _ _..._—t � __ _ - � I eertLty that in the perinrmance of the work fur which Yhis ,OISHWASHER � � '� ' permk is usued,i ahall not employ xny person in n�y mamiec ,� ; � 1 CONTRACTOR h f;�����{���f a�� , � UH so as to becorte subjeci to the FVork�r'Compensa?ioa Laws. �CLQTHES WASHER i I ADORESS G�(� ��� _�z � � . Date Appiicant . SWIMMINt;Pf10L RECEPTOR � ; � j �i s ` � ' CITV 1 L-� —' T E L.N O« F�,fJ U,� : NOTLCE TO APPL[CaNT:If,after mekirtg tlii��'ettificate of '� , --—� ! ,Y,� , tJ�'t J ,.��, �� LAWNSPRINKLERSYSTEM I �--����� p Exempfion, you should becnme subjer.t to [he Workers' � STATE LIC. p'1�-�, v, -"'_'— 1 1: CLASS �—o�� �.i. .. ° Comqansation provisLons c�Y the Labor Cnde,you must farth- ; LICENSE NO,. y � with enmply with such provisions or this permit stiall be � ��aTER HEATER � � _ .._...__ �i �. deenied revoked. � GAS SYSTEM OUTLETS � � DlSTRICT NO. PFiOCESSED Q.]L - { , ,€�� LICF.NSEQ CONTRACI'ORS DECLARATION OUTLETS OVER � �� � ' +-� ` I hereby affirm[hat I am licensed under provisions of fJhapter -� 5 P[R SYSTEM -���-��� �� � 9 (Commencing w€Th SCC41on 7000)Of Divlslan i qf�the B�Si- . � FINAL � _�.� ness and Professions Co�Sc,and my license is in tuil force and � U �' � � � '� DATE VA�'�D'4���� ��S effect. � /� �� y Li�eiase Numbet���i£� Lic.Class C—�� � BY .,�W„ �- � ConCractor�����'� ./ Date ��� '�� a v n *from the Ii�ensm re uirements as I am a �� P�an ChBCk fEe .� I am exei p_ B q _ . , Q � ?iten;ed architecC o� a eegistezed professional en neer � �� � F!Ui�AB!NG PERMIT ISSUIIVG FEE§ �' �� a actin� m my professional capacity (Section 7051,Bus- -�._ � inees aad 1':r�fess'soos Code}. ___ TOTAL FEE y� E�� � Lic.or ILeg:No. Dste � Pian check apU��cant - . � HOME OWNEP.-BFJILDER DECLARATION Name_____ - _ `� �Address �y R I hereby affirm ihat E am exempt from the Contractor's _—_. � g � ,� _ � License Law for the fotlowing ceason(Sectio�i 703t_5,Susl- ciYy Tel.No. � � � � ness and Professions Code): ,k,y� _ � � I,as owner of the property,am exclusively contracting ¢ � 'th licensed contractors to construct the project ` g {Section 704�k,Business and Prof'essions Code.). 1 � �. . 1 €�—�� � . � CONSTRUCTION LLNPING AVICNCY � � . � : - � � @ i hereby affirm that there is e conaYruetion lending agency - . � ; for the performance uf the work for�vhich this permi[ is � ��� _ . , - i�sued(Sec.3097,Ciu C_). . - � Lender'.s Name . � jLender'.c Address - . . � � � p I certify that I have read this apF>icafion and state that the �� � . � . }� abuve information is cur[ecL I a6ree to oompLy with all County _ g�g kF:VERSF.FOR F.XP7:ANATORY LANGUAGE _ �� � � � �. ordi��ancns and Siate laws regulating Plumbing, and heceby � authw�lze rep��esei�tatives of this County to enter upon the � - . ^ aboi -men�Uone �ro• rty inspcction purpases. �� � � � ����(J � 'm;�' _ /1 . . . . ��4f d� i Signature of Peimitt llate 1 .. � . . . _ . . . . . . ,. �� i p � ��'� �'� < ,�i� o' � m - � L� I� O 7 , n m . , � A � r, � c � � F rn ,� i2 7� .�� � � � . .. . . .�➢ p -i��� �. � �z � r 7.7� � O ,,,r . pr. p �� m � W < �. � C D W D � � r p . -n im mi i Z ;O!�n � � 'z -- ' �; r- � ;Q �,� -��.,. �� � 'F�. 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