HomeMy WebLinkAbout1145A (5) ' �� WOjIKER3"COMPENSATION DECLARATION �� ��
I hereby a(ferm thm N Frove o cenifim�e of mnsen�qo aelf �6ppp�p
APPLICATIDN FOR PLUMBING PERMIT ��
my�e�a u>:eAficqle af Workers'Compemotion J�sVronte, ��p%jkkV..10/8t)
or aceMiNetl eopy�hereoS(Sec.38p0,lp¢.C.) tOUNYY OF IOSANGECES BUILDING IiND SAFETY
aw oo3d�
cy�. .Compony.,��11Dr/NJI�� Fll Ll4k�'�- '
Cernfied copy ia hereby f�rnished. BURD.ING
� wa nvR�wr ro Fiu m lv�nNr oe rvae� �
Certified copy ie filed with fhe m�nfy bvi�ding inspec- AD�RESS
Kon deparrmen�. NfUMBER FI7(TursE ol+rtFM � FEE i
oa�e Br-�8-$7 wn�xcws�r �°r�w'r � _ R
_.appliSa�� �� '
CERTIFICATE OF EXEMP'�ION M WpRRERS' BAm� C} ��• 1
mM�vsnnoNiN r� ' � srowee p.�j °'"'''�" 1L RR1�11 '� �sk.f �
(Thls section nNd�rot b�eompbfsd tfYhe�warlc fe1wN'ed 6y .
thq parmtt b fot oes hvndrW dollan(3100)or 1eu.� y�vqTpay ;
f,� n"""oo��rss �17t� ��FGG
��entfy�ha�in�he peAormanee of�he wlxk far wMr�h fh�s �
peXtnit i�issuM.1 sholl notemP.�Y�y�sonin.enyV�enner � $ . � 8,C', TEL � - �� �
sa�ro beccma subjen ro Me�VYorkers Cpmpensatiqp�iaws. dSrtwAS� - . - �
� tp O eor�m"erore �� I.e) i 4u.mB�►/6
ome npp�imn, J c.Wlr+eswnst+ER - •�1
NOTI�TO ApPLICAM: If,qftet mok�r7g Ihib telli(}tafe of 5������ �� � W �
Exemptinr4 you shovl4 becnihe wb�est iq!hp Vfla.rken' .
Compenmflon prorisions of the labnr-Cpde.yov n+enf fiw�M �C�LIifIDORlf C,1} 1��/D�.�' r -f/$D
with corr�piy wilh s�fi prvrisivna or lhia paim�ahqll ba �`��NKtE�SY'''�EM `� ;
deemedrevoked.' r WATERHEATER .. . p� ��No. '3�?S9afl �'t� G �
USENSEp CQNiRqGfQRS pE�L+9Ri911�N p�tRIQ NU rRpcESsm er '
IharebYaffi�Yn�tho14om1icensed�uqderprWl;iolts�PELhaAter9 1 �s� o� . aCr !0 a, i
(cammendng wtth$@cliqn�[lflQ)of Dhision 3 nb(hq 8u3inosa ��� � � �
and Profe�iona Code.P�d rtW 1�Snme i�in IuA t?rS4R�effect. 9�YS�fF R }"SO DA1aE�' � VALIDATION Q 1
ticense Num6er 37�90D lic.Gaps .�� �� �1 7 �.5 A V 1
' FlN/ll . K i
' 8_$ . .. . BY {,!'• Y a • i..�i � l
Conhoctor pote �3 �
❑ i am mp�under Sec... _ . � � • � �2,J v � d �
N �
B.BA.G.fw this reoson ,PI04 fM9Ck�8@ � � , . ',• � �i 2.,�i 7 u Z {
Date: .. p�UMBING PERMrt lSSUING FEE S ' �
�;p„�w: D 'I1i 0?tG��87 i
roTu� Q
_ ;
� Plcn check appticam
51NGlE FqMILY , ,
HOME OWNER-6UIlDER DECIAQATlON Neme �
I hercby affirm tha�I am exempi from rheLonlmAor'e 4icense �
law fpr ihe following rqason�Seclion 7031.5,BVSinesy and �� .
Professions Coda): City - Te�.Nn. 1
❑ I,as owner of�Ae propeny,w�ll do�he work chd the - - �
strucNre �s�ot ie�erMed or offqr�s!frn w1e(Sep�on � . � � � .
7'044,Business cmd Profeasiom Cadey. , � �
CONSTRUf:T10N tENQING AGENCY
I hereby affirm rhar there�s o tomhuction lendingayertty fo. � � � I
�he par4qrmqnce of rhe work fw which thia permil ia iuued ,
ISec.3097.Cir.C.�. . �i
le�er'a Name
lerder a Addrrn � '
I cernfy ehm I hp.e road rh�s opp6�oiion arn!aro�e�ha��he " ,
abore information is ca.ect.I agree b tivmply wlth qll�ny � � - �
ortlihqncea and Stota lowa regvla�ing Plumbing,a�d fzereby '
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authvrize represenrotives of rhis Co�nry ro entar vpon�he - �� �
o6o�e-mentioned property fw inspection purposga. � �
SEE REVERSE FOR EXPLANATORY LqNGUAGE ;
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