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HomeMy WebLinkAbout1370A (7) WORKERS'COMPENSATION DECIARATION pppLICATION FOR PLUMBING PERMIT . � I he�eby,ofiirm thar I hove a ce.rifica�e of conaent�o self TBA687A .. . insure,or a cerlificote o(Workers'Compenw�ion Inwronte, CE 817(REV.B/88) . � � � ' � , or a ceriif�ed copy ihereof(Sec.�e0o lab.C.) COUNTY OF LOS ANGELES DEPT.,OF PUBLIC WOEIKS O�YNo.�79�39_42'�?��Y��'S�+r��,,,1 � � - ' . . Certified[opy ia hereby furnished. � FOR APPLICANT TO FILL IN(PRINT OR TVPE) g����' C�� Ceriified copy is filed wi�h fhe eo�nty building inspec- �R� tiondepartme�l. . . , NUMBER FIXTUREORITEM � FEE ����TY Dale�_APP�iqant -� WATERttOSET - NEAREST ' . , CERTIFICATE OF E%EMPTION FROM WORKERS' BATH TU8 . CRO53 5T. _ ��� COMPENSATION INSURANCE.� . S�R ONTIER . . �� . (This s�etion nNd no/b�eomplN�d if fh�work inwlwd hy � �i� _ IM p�rmlt b For on�hundr�d dallan(ZI00)or Ins.) IAVATORV qpp�55 � � .. . I certify Ihat in the performance of�he work for which this � _ permil is iuued,I sholl not employ pny penon in any manner SINK Cltt _ w ai b become aubjed�o�he Workers'Compenwfion Lows. � � � DISHWASHER - � CONiRACTOR � . .. Dale ' Applimnt �LOTNESWASHER � ADDRE55 . ��CE TO APVLICANT: I(, aNer making this Certifitote oi d "'S A � 1mp�ion, you should betome subjecf 10 �he Workers' SWIMMING PpOL RECEPTOR � ��CC.^�p2�sa��en prov+s�ons of rh�talxu Cnde,yeu must forlh- . �pWN SFRlNKIER SYSRM CITY T��.�o.(n3(o a with comply with such provisions or this permil aholl be STATE LK. Q '��deemedrevoked. � ' WATERHEATER ���N��� � �w� �� � LI;ENSED CONTRACTORS DECLARATION� �StRKT�10. PROCESSEO BY I hereb oMirm fhot I am licansed under ovisions of Cha tr 9 GAS SYSTEM WTLETS Y W P y (commencing wi�h SeUion 7000)of Div�s�on 3 of�M Business pU7�ET50VER A\O'n� � ond Proiessions CodE;a�d my lice�se�s in full force andeffecf. 5 PER SYSIFM FINAL VALIDATION (� DATE / �i � V License Number ��� lic,Closs y� FINAL 0 (� .� �� F Conhodor P Oe�e��1�..j_ BY �/ e�/� W � I am eaempi under Sec. � �' - N s.av.C.for+h�s reo,o� plan check fee Z �re� PIUMBING PERMIT ISSUING FEE E , ='j J 7.O A Signot�re � � TOTAL PEE h• • ° + •S .. .. . .. . � Plon check applican� � • •�]6,j� SINGLE FAMILY r l HOME OWNER-BUIIDER DECLARATION Name � - - -- � - • n e�']�,�O� lkeby offirm that I am exempt from the Contmctor i Litense qddross � - Low for the followinq reoson(Sec�ion 7031.5,Business and V'7.W�"O 7 , Professions Code): Ci1y Tel.No.. _ _ . . ❑ I,as owner of�he property,.will do the work ond fhe - structure is not interded or offered for sale (Section � � � � � , � � � � 7014,Bosinxs and Professions Code). � - _ � CONSTRUCTION LENDING AGENCY ' - � - - �--� - I hereby affirm that there is a tonst�uclion lending agency ior �he performance o(the wor4(or whith this permit is issoed � - � - � � - (Set.3097,Civ.C.). � . Lender's Nome . � lender's Address � � I cerufy fhot I have read ihis applicofion ood siaie that the � �-� � � � , � � obove infamotion is cwrcct.�agrae to tomply with all County � ordinances ond S�ote laws regubi�ng Pl�mbinq,ond here6y . . . . . . _ -_ . au�horiza rapresematives ol ihis County�o eNer upon fhe - above•mentioned property for inspet�ion p�rpotes. SEE REVERSE FOR EXPLANATORY LANGUAGE . •������co q-3-�-� Signa�ure of PermiNee Do�e � . • � ._ • . � C � •' 2 G1 Gl �c C ' . y� Z =' 3� c U D > U 7 N c- n = �. ;- H �+ c �: � ;� { _. � F < � c� �, : . i �..�..Y�.. ' }"7, '"�}..� D � �T s Gi c D : I , ,� -- � � F�' I �', :i�. �� x = s; t G ..: ; , , ;. i ;-- ;(' � y � '�:� �. •� � :, s; T ' �� � �.�� ;�,. i � i jl o �; N ° " � , � _ . :. i•. .� �.,� . i ''"'1, ; . . ,, __, ;'.,. 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