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HomeMy WebLinkAbout1376A WORKfRS'COMPENSATION DECIARATlON APPLICATION FOR PLUMBING PERMIT � � 1 he�eby,affrm �ha�I have a cartificate of conseM fo sel{ ,.�gA687A . . . . . . . insore,or o ceriifimte of Workers'Compensation Insuronce, . CE 817(FEV.8/88) . . � � - or o ceni(�le,d.�/t�o�ppy qthpereo9f{�ec.�800,tob.C.) 1 ' �� COUNTY OF LOS ANGELES DEPS.-OF�PUBL�Cy�V�fOAKS P❑olicy NoU.LD.1LLl—LomponY�-��e Fl/1!I . . . . . . � � . : ,�� . � �Certlfied copy is bereby fumished.� � � . � � � FOR APPUUNT TO FILL IN(VRINT OR ttVE) 8�����' � ��O� Centfied copy�s filed wi�h the coonry bu�tding inbpeo ADDRE55 � �u"�, tion depo���ment. . . NIJMBER FIXtURE OR ITEM � fEE ���ITV � � � � Oore_.l�.;:L_L._ADPIiSoN ,• � WATERCIOSET � NEARFST . . . .CERTIFICATE OF EXEMPTION FROM WORKERS'� BATH iUB _. . � CRoss Si. i F} COMPENSATION INSURANCE OWNER � - ''� � � � (Thb�Mion n��d nof h�eompl�Nd if fA�woh Involwd by SNOw�R 1h�p�rmif la for on�hundnd dollors(f100)or I�ss.) �qyqTpqy �'�� � �p ADDRESS . I certify ihot in the perlarmance of the work for which Ifiis __ peimil is issued.I sholl not emplvy ony person in any manner ` SINK CITY. �D���n � .q� � __ so as ro become subjecl to the Workers'Compenmfion Lows. - DISNwASHER �� , , � CONTRACTOR � pntr. �erplicont QOTHESWASt�ER �+ tICE TO APPUCANT: If, after making Ihis Certificoie of ���� � v� .fnpiion, you shoold become subject �o ihe-Workers' SWIMMINGPOOIRECEVTOR `Compe�w+ion provfsions of rhe lobbr Code,yov musl forth- CITY � �TEL.NO. LAWN$PRINKIER SYSTEM with comply with s�ch provisions or ihis permit sholl be 5Tq7E l tIG. deemed revoked. � - WATER HEATER ��N��� ` � �u � � � LICENSE�CONTRACTOR$DKIARATION �� � dSTRICT NO. M20CESSED BY �I he�e6y oHirm ihot I�om licensed onder provisions of Chapter 9 GAS SrSTEM OUTLEiS � 1 i.1 � (commendng wi�h Sec�ion 7000)of Division 3 of rhe Business . WitE7SO�fR �v �Q�O� > ond Proiessione Code,ond my licenK is in i�ll fwce ond effx�. 5 aER SVSiEM FINAL VALIOATION O License Number �13083 Lia Class C�`� � � �A� �/1/�� U fINAL � Contracror •Dote 9-.�-g� . BY � +-✓�-� d . � ❑ y� I om e.empl�nder Sec. a B.BP.C.for fhis reoson Plan check fee �1 3 7,b A = o���: p � , . . _ _ .. . .. . . DIUMBING PERMIT ISSUING fEE E ��' � ' '5 Signoture TOTAL FEE ( s °7 Q�� Plan check applicant - � � a 7(z,^,U� SINGLE PAMItY . . . . HOME OWNER-BUILDER�ECLARATION . Name � • . - - �C!�[G�-�-'] �� �eby offirm thar I am e�empf from�hs Contractor's Licence qd��ess ' � � Law fo.the iollowinq reoson(Secrton 7031.5,Business ond � Professions Code): . City _ � Tel.No. � ❑ I,as owncr of Il�e property..will do�V�e work and the . stroc�ure is not inronded a offered for wle (Section � ��� - � 7044,9usiness and Professions Code). � CONSTRUCTION LENDING AGENCY - " � I hereby aff�rm that there is a consnuction Ieoding ogency for � tFe performonce of rhe work for which this permit is isaued � �� � - - -� � - �- � � - - -� � � � (Sx.3097,Civ.C.�. � lender's Name - � lender's Addrosa - i cerrify that I have road this applico�ion and slale�hot the � - � - -� - ► - - � above infwmaiion is corrxl.I agree�o comply wiih oll Cou��y ord�nances aod Sta1e laws�egolo�ing Plumbing,ond heraby . .. . o��hori:e reprosentotives o1 ihis CouNy to enrer upon�he � above-menlioned property for inspeU�on purpo:es. SEE REVERSE FOR EXPIANATORY tANGIIAGE �o�� ' ,�� 0 9-3-�� Signalure PnmiHe Dole � �- .... .. ,. � . _ . , � c, •, - � c� „ � N� j; = � � U t/� N cU-. o . 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