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HomeMy WebLinkAbout1371A (7) ,WORKERS'COMPENSATION DECLARATION �qpp��CAT10N FOR PLUMBING PERMIT � I hereby,afii�m 1ho1 I have a cer�iFica�e of consent io self 76A887A insure,or a carfifico�e oi Workers'Compensalion Insorpnce, CE 677(REV.8/8B) - � -- � ' ' cr a certified copy thereof(Sec 3800 lob.C.) � �- - � � � � � � � '' „ ��e�v� COUNTV OF LOS ANGELES ^DEPT: OF.PUBLtG WORKS D�y"°���^Y ` � ' �. 3 Ceriified topy is hare6y furnished. BUao1NG � � FOR APPLICANT TO FlLL IN(PRINT OR TYPE) A��� O Ceriilied copy is filed wilh!he tounfy boilding inspeo- � lion deporime��. , . MUMBER FI7RUREOR iTEM � FEE ����T, Dote�—Appii5anl ��e-� WATERCLOSET NEARESi . CERTIFICATE OF EXEMPTION FROM WORKERS' � � 8.4TH TUe . CrtOSS 57. . , COMPENSATION INSURANCE� OWnIER � � - (This���1ion nwd no1 b�eomplN�d IF Ih�work inrolr�d 6y SHOWER MAfl fh�p�rml}h for on�hundnd dollars(f100)or Inf.) LAVATORv � app�5,5 _ ' � I ce�nfy thot in�he perlormonce of Ihe work fw which this ��- � permil is iuued,I sholl nof amploy ony perton in ony manner 1 SINK � Cltt v� v�7.!'�,\ � q�, -� � so os io become subjec�io rbe Workers'Compensofion Laws. pISHWA5FIER � va ��ra�.� � e P ��te epplitont CLOTHES WASNER b'U App{�fu < � 'ICE.70 APPLICANT: If, a4�er moking�his Certifica�e oF � v �� ..�mpGon,.you should�become subjecr to the Workers' SWIMMINGPOOLRECEPTOR -� Compe�sa�ion provisions of fhe Lo6or Cade,you musl forth- �AWN SVRINKLER SYSTEM CITM � e `'��� �� -with comply with such provisions or rhis pe.mif shall be 57AtE ^,`� lrC. � deemed revoked. � � � � '� � WATER HFATER ������ v1�� �u �� � LICENSED CONTRACTORS DECLARATION � DiSTRiCT NO. PROCESSED BY � I hereby aHirm thot I om licenied under povisions of Chapfer 9 GAS SYSTEM OUTlFTS O {(}�a��n� (cammencing wi�h Seceion 7000)of Division 3 of the Business OUTlEiSOVER 1�� Y ond Profassions Code,and my license is i�full fwce ond effect. 5 GER SYSTEM FINAL � DATE �/��/�'� VALIDATION � License Number �13083 Lic.Class .3�e FiNni �yM/ a conrrocro, �c —9 ��_ B� ✓ V � I am exempl unde�SBC. W a B.&P.C.for this reason � Plan check fee = ��e� PLUM8ING VERMIT ISSUING PEE f , :'•� J�,� A SignoWre i ' TOTAL fEE s �r• • • • •S , .. . . . . . Plan check applicanr I + •7 Q J 0 . . SINGIE FAMILY � HOME OWNER-BUILDER DECl.4RA710N Name � . u .j(y;�Q,_=� � �eby oKirm Ihot I am exempt fiom�he Conkatbr't Litense . � - ;av�'ar!he fo!!owing rsason(SeUion 7631.5,Business ond Address � �9,�4,�8 7 Piofeesions Code): Ci1y Tel.No. ❑ I,os owner of the property,will do the work ond the srructure is not in�ended u offered for mle(Secfioe � -� � . � � � -- - 701�,Busines:ond Professione Code). ' CONSTRUCiION IENDING AGENCY �� -� � � �" � � - � � - � �hereby aftirm tha�rhere is a tonshuc�ion lending apenty for � �he performance of the work for which�bis permit is issaed - � � �� � - - � �� (Sec.3097.Civ.C.). . lendels Nome � Lender's Address I certify�hof I fwve read ihis applicotion ond sia�e�ho��he � � � � ► � . � --� above infamoiio�is cw�ec�.I ag.ee�o comply wirh oll Couny ordinonces and State laws regulating Piumbing,and hereby _ _. . . . . .. . . . . authori:e represen�o�ives of this Counly lo eMer upon 1he � o6ove-mentio�ed property for inapettion p�rposes. � SEE REVERSE FOR EXPIANATORY LANGUAGE ���,�D 9�3-g1 � SiqnoWre of Vermittee Da�e � ' ' ' - c n � x ��� r_ N� T N ` "�� � N C� C) m y K �-w' � ! � �1 jo � ` _ ; p-.. ..r-. . ��, � � ;• i- � " -� �[� r .I � I . . � —� � 1 T j` �' Q � y Z r' y � ' Lr` I � �•� I Y_ T 1 � a: i . ;�.� . O� y ,y'Y: � Ic ' O I , � ' -, !� F.Z;I � T �.�= y � �y U < 1' - :f'� ��, ,�'� 1 c>qr �- � � I'� I :` � •C �1 1� I U �ly �~• �.•, �Lk.. 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