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HomeMy WebLinkAbout1002A (5) � WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT /�I :I hereby,offirm 1Fnt I have a certifica�e of consent fo self �gqgg�p . � � .insuro,'oca cer�ificote of Workers'Compensalion Insurance, CE 817(REV.8/B6) � � � � �� - o.a.erfifed copy thareof(Sec.3800.lab._C.) . . �WGD03aS�"0pp3 COUNTY OF LOS AN(iELES DEPT. OF PUBLIC WORKS •P❑o�icyNo.T_Company ►J�'�IOJfLt)111�L }'V)1�t'fU/3�. , �' - _ , .. Ce���(ied copy is he�eby furniahed. {� / � - � FORAVMI�ANTTOFILLIN�VRINTORTVPE� BUILDING v�GKI��O 11ORSG . Cenified copy is filed wi�h!he coanty buildinq inspec- A��Eu a 3s9 !� tion deportment _ NUMBfR fIMURE OR ITEM � FEF ��`rcY . ����� �n O.�I Dale�d�27�.C_L_ApPliSanf WATERCLOSET � �/,Gv NEqREST . GR06S ST. � � � I CERTIFICATE OF EXEMVTIO f M WORKERS' &4iH TU9 , COMPENSATION 1 RANCE OWNER.. (Thic��cllon nNd irof b�tomplN�d�f fh�work Inrolv�d hy S�+OwER 1 � . . 1h�p�rmil 1�for om hvndr�d dollan(=100)or I�n.) UVATORY aDDIRE55 � . . I cerlity thnt fn�he performante of Ihe work for whkh fhis � � �, permil is issued,1 sholl nol employ ony person In any manner SiNK D0 CITY �G ?EL'hp. so as ta become subject to the Workers'Compemation Lows. � I - DISHWASFIER �Q�pRpp � �� h0 I �pl@ ' OppiiCant � 0.0TNE5 WASHER �� , NOTICf TO APVLICANT: If, af�er making.this Ce.fifico�e of SWIMMiNGPOOIRECEvtOR A�� D L � � � Exemp�ion, you shouid become subjecl lo �he-Wohers' Compensor�on po�fsions of�he lobcu Code,yeu must fonh- CirY � � p' n TEL'NO �OS tAW7J SPRWKLER SY57EM wi�h comply with soth�provisio�s or this permil aholl be STn1E LK. ' � deemed revOked. � � WATER FiEATER ��N��� �� C1A55 � ' UCENSED CONTRACTORS OECLARATION � DISTRICi Np.f WtOCE55E0 BY �- �I hereby offirm rha�I am licensed under provisions of Chopter 9 ' GAS SYS7FM g ounei5 p� /�'� (tommenting wi�h Seclion 70pp)of Diviaion 3 of Ihe Business O�TLFTS OVER O ` n/�i pT,, ond Professions Cod�,and my liceme is in full force and effecf. 5 RR SVSTEM �• FINAL f„� V IDATION V DATE lJ V ' Licenx Number ���qvG Lic Closs�_ 0: � � - � FINAL � � - O� Contractor Daie 8-�4-8� sY � . V ❑ _ 4t I om mp1 under Sec. y � .... B.BP. .for this reason pian check fee - � - � � - . �1e�. PLUMBING VERMIT ISSUINC,FfE S -- Signolure TOTALFEE OO � . � vlon check opplicant z'1 �Q 2 A SINGLE FAAhILY HOME OWNER-BUILDER DECLARATION P�ome - , n• • • • •Jr I hereby oHirm that i om exempr from the Contractor i ticense Address . law for�Ihe following reason(Section 7031.5,Business ond � • � 4 7,�� P.ofe�sions Code): �ity Tel.No. � � • � 1 47,00� I,os owner of rhe property,.will do the work and rhe . . strudure is not intended or oRered fw sale (Seclion � � ��2 a��7 70a<,Bwiness ond Proieestons Code). CONSiRUCTION LfN01NG AGENCY � � � I hereby affirm thnt there is o consrruct7on landing ogency for . the parformance of the work for which thl:permit is iewed - � - � � � � � � - (Sec.3097.Civ.C.). Lender's Nome lender's Addresa 1 certify thot I have read�his applimtion ond stole thot rhe - ► � obove informa�ion is cwrxt.I agree io tomply wi�h oll Co�nty . ord�nonces and Sta�e lows ragulating Plombinq,ond hereby � , � � outho�i:e reprcsen�o�ives oi�h�s County to en�er upon the � - . obove-mentioned property for inipec�ion p�rposes. � SEE REVERSE FOR EXPLANATOR�LANGUAGE �,�,;�� Q:�y-g� �� Signotur e�miltee Dofe �� S � n �+ c I . . . . .�1 _ 'r'- 1 r -U'� v� �' C `�� . . _ .. ' j,�� _ � ,. � � �� N . ��- �, -C m � L .v � tn , ..-� " n `� �i �� m i 4: � � . - ^ --;„ - ,,l, Q U I A - a �� '� �: �; Ci . . p• �� v - ( x, ?= . , �'� � �I;' ,� y` - ^` ' . 1� � N . .. ' � � � `' .�. 1� '�% � �'.�;� V �1 I � ; . ^ '.i� � �. � .. , �+. `'' �'„ti i .��.1 `. , - ' '� r' -1 j .^ , � ` � '� � � � .i � � � h .� I i i �".1: F� y r .�, �.. . 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