HomeMy WebLinkAbout1237A (6) ' 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 � ,
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� � 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 . . . .
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i Signature of Peimitt llate
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