HomeMy WebLinkAbout1780A WORKERS'COMPENSATION DECLARATION � APPLICATION FOR PLUMBING PERMIT y I
I hereby oFfirm that I have a cer�iiicaie of mnsent to seli � 76a667n ' � �
insure,or a ce�rifimte oi Workers'Compensation Insorance, fE 617(REV.10i81) . . .. _ . . .. . . � � L�
or a rer�i�copy�h�(,Sqcf3BQ0,`ab. .� COUNTY OF l05 ANGELES BUILDING AND SAFETY
cv�.i.�,'CJ.X��'` �
Qq No. 1�� Compony ., -
Certified copy is hereby furnished.
� � FOR APPLICANT TO FILL W�PRINT OR TYPE) BUILOING 1`Z 1� 1� ��
Certified topy is iiled wiih ihe tounly building inspec- ADDRESS l J 1 v
fi n deporlm t � � NUMBER FIXTURE OR ITEM (� FEE
Q �J�i�j � f LOG4LITY `������
Date I Z� �APPIicaM ��� WATERCtOSET NEARE57 /� /��,n /y^'
CERTIfICATE OP EXEMPTION FROM WORNERS' BATHTUB CROSS 5T. l..�v,• '�.� C�'II��- -
� � COMPENSATION INSURANCE ' OWNER r'e� -Q- � �
(This��etton nNd no1 b�cempl�eod II fb�work invo v�d 6y • SNOwER .
MAII /a Q� ` � :
fh�p�rmH b for ons hundrod dollan(5100)or I��f.) , IAVATORY � A�DRE55 "G L /
. I certify Ihot in the perFormonce ot Ihe work for which ihis '
_ permil is issued,I sholl nol employ ony person in ony manner � SINK CITY ��/�v;��- TEt.NO. _
� so as to become subject to the Workers'Compensmion Laws. � �. �
. DISHWASHER . CONTRACTOR �(�'/ y ^
�L/�
Date Apptimnt � CLOTHES WASHER AODRESS ��^'+/�"'6 r � �G/�[� � �
NOTICE TO APPUCANT: If, ohar moking this Ce�tifimte of
Eaemption, you should become su6jed �o �he Workeri SWIMMINGPOOLRE�EPfOR
��TY � TE�.N .630�6�
Compansa�ion provisions of the Lobor Code,you musl Forth- � (qWN SPRINKIER SYSTEM v � �� �
with tomply with such p�ovisians or Ihis permit sholl be - ? STATE IIC. �"' /J �
dBBmBd f9voked, � . - WATER HEATER ���N�No.L/3�3 J�3 CL455�/� ` _
. LICENSED CONTRACTORS DECIARATION DiSTRiCT t�0. PROCESSED BY
I hereby offirm fhot I om licensed under provislons of CFwpter 9 ' - �-+`SYSTEM� pUTtETS •7
(commenting with Section 7000)oi Division 3 oi the Business oui�[T50vER ��
ond Profeuions Code,and my license is in full force and eifect. 5 PER SYS7EM FINAL VA�I TION
3l .�� �� DATE r. �{��f, O
Licanse Number lic.Closs
^ ��/ �/� � / ��l�� FINAL - U.
Conkactd�'tyt «'�'�`c �' � �� Bv
�
� O
I om exempt under Sec. H
U:
B.BP.C.for thia reoson W
Plan check fee , N
Do�e: pLUM81NG PERMIT 15SU�NG FEE E Z�
- 51 nolure ' �'
9 TOTAL FEE �1 7 8 0 A
� � � � . Plon check applicanl �� � � � �5
SINGLE FAh�ILY
HOME OWNER-BUIIDER DECIARATION Nome � I • • � �i S O
II here6y aHirm Ihot I om ezempt from the Con�mctor's License Address ' � r. _ �
� Law for the iollowing reason(Section 7031.5, 8usiness and - � ' � ����+
Professions CodeJ: City Tel.No. O�,O H—H�I
❑ 1,os owner of ihe prope.ly,w�ll do�he work�and Ihe
structura�is not iNended o�offered fo�sale (Sec�ion ,
, 7044,Business ond Professlons Cade). � � - ��� �
� CONSTRUCT�ON LENDING AGENCY . . �. . , .
I hereby nffirm thot there is a conslruttion lending agenty for . �
fhe performance of�he work ior which ih�s pe�mit is issued , . . .
(Set.3097,Civ.C.�. . . .
Lender's Name . � . . . . . . . . . . . . . . . .
Lender's Address � � '
I certify Ihol I hove read Ihis apptico�ion ond stale Iho1 Ihe � .
above information is mrreU.I agree to tomply with oll County ' � � �
ordinonces and Srate laws regulo��ng Plumbing,and hereby
� aulhorize represeniaiives ol rhis County to en�er upon ihe �� �
obove enfoned prope�ty for inspection purposes. � - �
�� ✓� SEE REVERSE FOR EXPIANATORV LANGUAGE
�
SignaNre of Permine Date �
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