HomeMy WebLinkAbout1773A (10) WORKERS'COMPENSATIONDECLARATION ; . APPLICATION FOR PLUMBING PERMIT � �
I here6y ailirm that I have a rerlificole of mnsenf to self � 76A667A
insure,or o certificate of Workers'Compensation Insuronce, � CE 917(REV.10iB1) . �
or a ce��if�dyovy-�hs�eof��r�3eoo 1 .C. C,� COUNTY OF lOS ANGELES BUILDING AND SAFETY
` cra��> a
P❑ollcy rlo i Company , _
. Ce�fified topy is hereby furnished. / �^
��--1 FOR APPII�P,NT TO F�LL IN(PRINT OR TYPE) BUIIDING 1 ZI �./��� 'y �
�ryy--Certi(ied copy is filed with the to�nty building inspet- ' AD�RE55 �
b'� !!��✓^���d777e� �� / /y NUMBER FIJ(TURE OR ITEM (� FEE ����TY �
Da�e�ApplicaM'"' `� , �^1l+TERClOSET � NEAREST /�� �
� CERTIFICATE OF EXEMPTiON FROM WORKERS' BA7H TUB � CRO55 ST. �i 4 WIiY11�
COMPENSATION INSURANCE SHOWER OWNER ]
(Thh eeefion naad nof bs eomplabd if Ihr work lnrolv.d by I�' �,
ths p�rmil It for ono hundr�d dollon(3100)or Ins.) LAVnTORY MA�� �, `7� � � t�c/KiF � � � -
aow:ess
I certiiy thot in�rhe performance of�he work ior which ihis �,.y-f1/� -
ermi�is�ss�ed,I shoil no�em lo on erson in an monner SINK CiTv 7EL.NO' L_�� YJ
P P Y Y P Y �C,1 r)t
so os to become subjecr 10 rhe Workers'Compensalion Laws. . D�SHWASHER �i
- CONTRACTO
Dote Applimnt � CIOTHES WASHER ADDRESS �, ��� � _Q
NOTICE TO APPLICANT: If, afler moking this Certificate of ,
SWIMMING POOL RECFPTOR
Eaemption, you should become subject io the Workers' CiN /�^ TEL..N . �
Compenwtian pravisions of ihe Labo�Code,you must forih- (AWNSPRINKlERSVSTEM ��/-� ��
winc �omply wifh such,provisions or this permi� shall be SiniE [J3/�y�� �AS " r-�
deemed ievoked. ' WATER HFATER � � LICENSE NO. � � /�� c��
IICENSED CONTRACTORS DECLARATION DISTRICT NO. PRpCE55ED BY
I hereby�affirm 11wf 1 om licensed under provisions of Chapter 9 GAS SYSTEM OU7lET5
(commencinq witli$ection 7000)oi Division 3 of Ihe Business OUTlET50VER
ond Professions�ode,ond my license is in full(orc ond affect. 5 aER SVSTEM FINAL VALI TION
license Number�l3l3� lic.Class�� DATE �//}/,� p,�
/� ��,� O
��'"'�(f��'b`.J-�T�� � �-ci/ BY Al U.
Contracl . . .
�
❑ I om eeempt under Sec. � �
U
B.BP.C.for this reason W
. Plon check fee ► n.�
ooie: �
PIUMBING PERMIT ISSUING FEE f Z
SignoWre - �
. TOTAL FEE "-�� 7 7•3�
. . . . Plon chack applicant y o • • o 0 5
SINGIE FAMILY ' �
HOME OWNER•BUILDER DECLARATION Name -. � I • • � 6 Jr O
I hereby afiirm ihot I am exemp�from�he Conhac�or's license � �
law ior the follawing reason(Section 703I.5, Business ond . Address � • • • 1 6 5 0 u
Profession�Code): , City Tel.No.
� 0 1.08-87
I,os owner of ihe property,will do the work and the
stracture is not iNended or of(ered fof sale(Settion �
704�,Business and Professions Code). - - �
CONSTRUCTION LENDING AGENCY �
I hereby nffirm Ihat Ihere is a mnshuctian lending agency for . ,
Ihe performance of Ihe work tor which ihis permif is issued �
(Sec.3097.Civ.C.}. . . - . . . . .
Lender i Name '
lender's Address ' � -� � - " � - �
1 cerrify�hat I have read this applicarion and state�hat tha - � ► ,
obove informa�ion is correU.I agree�o comply with oll Couny � -
ordinances ond State lows reguloiing Plumbing,ond hereby
outhorize represento��ves of this County to en�er upon the -
a6ove•ment�oned propen fo�inspecfion purposes.
,A��� � ���j� SEE REVERSE POR EXPIANATORY LANGUAGE
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Signature of,Perminee Date - - � - �
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