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HomeMy WebLinkAbout1301A (7) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT � 1 hereby,off�rm tho�I have a certificaro of consen�to aelf 78AOB7A .. . . � insvre,or o 2ertificate of Workers'Compernotion In�uronce, CE 817(REV.8/88) � -� - � �� � �� -- - or a cerriiied copy rheroof(Sec.3800 1a6.C.) j� . - . ' volicy No. Compony �Pd�-'�` COUNTY OF LOS AN�ELES OEPT. OF PUBLIC WORKS ❑ Ce�liiiad copy�s he�eby furnished. BURdNG - �'" FOR AGPLICJINT TO FIIL IN(PRINT OR TYPE� �R� �a. �C���� Y"'Y Ceriified copy is filed with the county buildinp inspec- /`"' lion depar/men�. NUM�BER FI%TURF OR IIEM � FEE �����, Oat�ApPlitanf -� � WATERCLOSFT NFAREST � . . . . .. CERTIFICATE OF EXEMPTION WORKERS' � BAiH T118 . CRO55 ST. COMPENSAiION INS NCE. S�OwER OWNER . - � � (Thi�i�etlon m�d nof M compl�f�d if�h�work Inrelr�d by fh�p�rmil Is for om hvndred dollan(f100)or Int.) �qVATORY M�IL ? ' �/� � . . I car�ify t{qt in ihe performante af.lhe work fot whith this A��� � 7 permit is issued,I shall not employ cny penon in ony monner SINK QN . 7E1.NO. (� � - - so os to bacome subject to fhe Workers'Compemation Lows. � DiSHWASHER - CONTRACTON . pa�p � ' APp�j�pM � - CLOTMES WASHER ��� ' ' NO710E TO AFPLICANT: If, af�e� moking rhis Cer�ificme of a � �Eremp�ion, you ihould become subjxt �o the Workeri SW�'�'W'������ CITv w�-� i.� �'/S'l �� � iFl.NO. 1 Compenwlion povisio�t of Ihe Labor Code,yo�must forth• tAWNSPRINKLERSYSTEM ��wi�h comply wilh nuch provisions or this permit �holl be STwTE liC. �J� �� deemed revoked. �- � � � WATER HEATER ����� �5 � � ll'�NSED CONTRACTORS UECtARATION � dSTx�Ci NO.� PROCLSSED BV � I Alreby aNbm tFql I am IiteMeJ Vr�e�povis�otn ef CMpIM 9 GAS SYSTEM � OUTLEfS � � � ([omme�ting wi�h Seelion 70p0)af Divhlon 3 of�he Business pUTIETSpyfR �- ond Proiessiom Code,ond my li�nse is in{ull{mce ond effxt. 5 aER SrSiEM FINAL `L� -&� VALIDATION d DATE V Litense Number �� Uc Closa�..�.,�_ O a Q`, �j FINAL Controtro�.���� Dale�� BY U � 1 pm exemp�under Sac. W 6 N s.ar.C.fo��h�s reason ' picn check fae � Z ���� PLUMBING PERMIT ISSUING FFE S Q � Signoture TOTAL FEE Plon eheck appliwn� SINGLE FAMIIY r` � , HOME OWNER-BUILDER DECLARATION Nome i � �- � � 1 hmeby offirm ihal I om eaempt irom Ihe Coehallor't Licenu . Addroet p.. C� � � '-� � ' - � - � � � - law fo:t..e.cl!owinp reoson(SeUion 7031.5,Bu�inees ond `�p � . Proiessions Gode): �;�y Tel.No. '� `" ❑ I,ns owner of tf�e proparty,will do the work and the ��rocturo is no�in�ended or offered for wle(Secfion � - - � � � -� --� , - - �-- - 7044,Buainess and Professions Code). . CONSTRUCTlON LENDING AGENCY - � � - " �" " � � � �� 'J Q��Fl I hereby oNirm�haf there ie a tonahuction lending ogency for �he performonce of IFe work for which thia permii is iewed - � � - � . i�" •• • •5 , (Sec.3097,Civ.C.). I r �1 6,50 Lendei s Name • + � 1 b 5 0� Lender s Addross �q�2�a 7 . I cerrify lhar I hove reod rhis applicotion and s�o�e rho��he � � ► � �� -- o6ove informa�ion is carxt.I og�ee ro comply with ull CouMy wdinancea and Sb�e lows regulo�ing Plumbing,and heraby . . . . . . . . oulhorize repre�entalives o1 Ihis Counry to eNx upon the � . above-menlioned propprty for inspec�ion pu�poses. SEE REVERSE FOR EXPUINATORV WNGUAGE � ���--P� Signa of Perminee Dare - / ' .� . . . . ... . :'I T C � � T � � S C . . � D V � - D C U I, y O 7 J c � �+ ; - in in c o . . . . I , : . , . ^'-' < .. w L c n Cl A ' I � � �� ' n N D T N D ' I ' I i .I' I ,�I, � O � }� �W C, a� " -. I �, I c> ! V x T � c - _ I '. I i E' , I ' � ~� � . I I"' ' ., ' � ' �:, m, i� �� x> r 1 I . , � 1 V �, i; '.�. n `v� r_j i j � 1 . 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