HomeMy WebLinkAbout0850A (4) ,� WORKERS'COMPENSATION DECIARATION y �^�'~ ~�"'—Hfi-�.�GATION FOR PLUMBING PERMIT� �� � ' {� I
I rereby oflirm that I have a certifimre of consenl to self �yAyy�A � , .� � - • � �
i.,'sure,or a tertitimte of Workers'Compensofion Insurance, CE BV(REV.10/91� .-. �. . .. . � - .- ' U
�or a cerlified topy Ih ieof(Sec 380 Lob.C)
'' :,'. ,. ' .,..: ....
� � Da�D - - COUNTY OF LOS ANGELES BUILDtNC�AND SAFETY
POolity Company ; . . - ,�- . �
Cenified copy is hereby lum�shed,
� - FOR AP7LIUNT TO FILL IN(PRINT OR TYGE� BUI�DING ' ' ' � n
Certi(ied cvpy is filed wi�h the counry building inspec- ADDRE55 /� C..�Q
tion depa Imenl. . � NUMBER� - FI%tUREOR I7EM � FEE .�/
C1����",, LOC.4lITY � 'am0. , ' pv� I
Date__L��!j.��•t AOP�iSOM I � . _.. ._ '_ WATFRCLOSET.. . .. .. . ...... . ._. . QO ry�AREST . .
� RTIFICATE OF EXEMPTION fROM WORKERS' BA7H TUe `. ��, CRO55 ST. � .
� � . COMPENSATION�NSURANCE��- - SHOWER �W�R �� � -
(Thb-�Mion nNd nol b�comp6bd if Ihs�+ork involwd by �� •
nnan
1bs permit If!or on�htlndr�d dellors(SI00)or ins.) IAVATORY AODRF55 -
I cer�ify�hol in�he periormance of�he wak for which Ihis ' �;
permif is issued,I sholl no�employ any person in any manner �� �"�� SINK� � ��� �� � � �� -��-�-� �- �� ��� ��� O� [I �.- �,��
_ so as ro become subiect fo rhe Warkers'Compensotion Laws. DiS�iwnS�+ER �
- � G-- CONTRACiOR /S �/
�ob Applicant� - CLOTHESWASHER 0 A�E� � �_) •�// �
NOTICE TO APPLICANT: H, afie� making this Ce��ificote of ���� t '
EKemp�ion, you should 6etome subjec� to fhe Workers' SWIMMING POOL RECEttOR
CITY
Compensofion prov�sions of the lobo*Code,yoo must forth• � - - �qWN SORINKIER SYSTEM � � �
with comply with such provisions or this pwrmil sho�l be SiA7E p IIC. A +J!_ '
deemed ravoked. ,, , . . -�- -�-- WATER HEATER ---- � � - - � - � .O� LI�ENSE NO. 7 CLASSG�'9!P
� LICENSED CONTRACTORS DECLARATION � �iSiaiCr nip. ESSED ev .
I hpeby offirm ihpl l am licensed under provisions of Chop�er 9 GAS SYSTEM OUTLETS O, � -
(commencing wirh Sec�ion 7G00)of Division 3 of Ihe Business OUTIETSOVER ,
and Professions CoJe,ond my license is in full forta ond eHect. . 5 PER SVSTEM FINAL ?� VALIDATION �
_ �
license N err��Lic Closs ��3� ��� (� DATE �' ._ . . O:
, . . .. . . .. . . . . . . .
� �/ v FINAL . . . . V ,
Coniractor Da�e �/ �a BY
._� -__ .. __ ... .__. ..._.. . _ . .... . __._ . Q+,
. ❑ I om e�empf under Sec: � - �:
. ...... .. ......._ ._ ... _....... .. . . . . .. .
B.BP.C.for Ihis reason � laVj
Plan chetk fee a
Dafe: p�UMBING PERMIT ISSUING FEE E 6 O ^
Sig�olure . . . . . ..
TO7AL FEE :Q S S.O A
. � ... P7an�check appliconi_ ._ . .. ....__._.. . .. ..... ... . . �• • • • ��j ��
SINGLE FAMILY
HOME OWNER-BWLDER DECIARATION .. Name . � I • 1 3 6.5 0
I hereby oHirm thot I om exempt from the Controctor'S ticense Address � �� � / (f � - �� '� � • 1 3 Q 5 9 Ei
Law for 1he following reoson(Sedion 7031.5, Busineu and . _.. ,_ , . . . ...
Professions Code}: � City �A Tel.No.3 ��� 8�8 7 �
❑ I,os owner of Ihe property,will da the work and the � " � . '' � � � �
structure 's no1 intended or offerad for wle($ection , �
7044.Business and Professions Code). ...... .. .....—._ .._.._ __... -. � . .. ._.._ ._._._... __., . .-.- _-._.. _. . . . . .. . ;
� �""CONSTRUCTION LENDING AGENCY � �
. . . . . . ... .. . . .
I hereby nffirm that fhare is a conslruUion lending agency for � �-- � � � - - - � � - - � � -
the perPormance of the wor4 for which this pe.mit is issued �
(Set.3097,Civ.C.). ....-_ __ _.. . .
. . ._ . . . . _. . . _ .. _. _ ... ..... _.. . .. . .. .. . .
lender's Name �
Lender's Address . .. . . � . . .. . . -.. - .. . .. .
I cerrify�hot 1 have read�hrs opplico�ion and sioie tho��he � � � - ,� " � � -
abave informvtion is correcr.I ogree io comply with oll Counfy ---�- � � � -� � �- � - - � � � � � �� - -
o�dinonces ond Store lows regulating Plumbfng,ond hereby �,
authorire repreiento�ives of this County to enler upon�he . . . . . - . . . . . .. . . . . _._ .. � �
obO e-menffo�e property for inspecfion pu�poses. �
1 ( p. G qn SEE REVERSE FOR EXPLANATORY LANGUAGE
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