HomeMy WebLinkAbout1781A WORKERS'COMPENSATION DECLARATION APPLICATI�N FOR PLUMBING PERMIT {�
I he�e6y otfi�m ihot I hove a tenifico�e of mnseM to self 76A667A •
insure,or a ceriifimie of Workers'Compensa�ion Inzuronce, � CF 817(REV.10i81) � . L�
ar a cert-i7fi�ed copy ihereof�5 c.3800,La(h.C.) /�� � COUNTY OF LO$ANGELES -BUILDING AND SAPETY
Policy NY'���d��pmp�o�n�y �'TTI.� IeCMt.R�'
� Cer�i(ied copy is hereby furnished. , ��
FOR APPLtCANT TO FllL IN(PRMT OR TYPE) BUILDING '�
Cerlilied copy is filed with�he county building inspet• ADDRE55 i 'f�Gh
fi n d rfinenl. NUMBER � FI%TUREOR ITEM @ FEE ���ITY
Da�e �r���Appli4an� WA7ERCLOSE7 NEAREST C �}� IM ..
CERTIFICATE OF E%EMPTION FROM WORKERS' ' Bn.Tti 7UB CROSS 5T. G�tt� �LxJI!,`LG� �
COMPENSATION INSl1RANCE OwNER �"'��
SHOWER
(ThD�ecFlon ne�d not b�complN�d IF th�work fnvolved by , Mna . G�� �
Iha psrmif Is ior one hundrad dolivrs(S100J or lass.) LAVATORV ADDRESS �
I certify ihol in Ihe performonce of tbe work for which Ihis � �
.permil is issued,I shall not emplay ony person in ony manner SINK CITY t�;�./J 7E1.NO.
— vu��
so as l0 6ecome s�6jec1 fo Ihe Workers Compensalion Laws. : DISHWASHER
. � CONTRACT � /'�lv.�� �
Da1e epplimnl � CIOTHESWASHER AD�RE55 � ��
NOTICE TO APPIICANT: If, after making Ihis Certi{icote of
Eaemption, you should become subjact fo fhe Workers' SWIMMINGPOOLRECEPTOR � ��.._.,�
Compensotion provisions of 1he Lobo�Code,yo�most forlh- �p,WN SPRINKlER5Y5TEM CITY �C TEL �J"
wi�h comply with such provisions or this parmit�shall be SiaTE �/�� tiC. /'ti17�
deemed�evoked. WATER HEATER tICEN$E Np. C1A55 �C-T
IICENSED CONTRACTORS DECLARATION DIS7RICT NO. PROCESSE�BY
I hereby offirm thot I om Itcensed undar provisions of Chopler 9 � GAS SYSTEM OUIlETS • -
(commencing wi�li Sec�ion 700D)of Division 3 of the Businass OUT�ETSOVER
ond Professions Code,ond my license is in full force and effect. 5 PER SYSTEM FINAL {/ALI ��N
license Numbar�-1�n �3�� lic Closs�� DATE ''��F� O
Contmct��^-�l U+����et I�—J� BMAL U.
�
� , O
I am e�empt under$ec.
B.BP.C.for ihis reason V
Plan check fee pW„�
Dote: p�UMBING PERMIT ISSUING FEE E � � Z
Signa�ure '�
- TOTAL FEE �� ']�� A
. ... Plon check applimnl �• • . • •�
SINGLE FAMILY -
HOME OWNER�BUILDER DECIARATION Name - I • • � 6.S O
I hereby affirm�hat I am e�empl from Ihe Conirac�or's license qddress
(aw for the fcllowing reoson(Section 7031.5,Business and _ . , • • • � �5 O�
Professions Code�: City Tel.No.
❑ i,as owner of ihe propery,will do�he work and Ihe �O L O E3-S 7 �
� slrocture is not iNended or ofiered for sale($ection _�
70�4,Bosiness ond Proiessions Code). � � � �
CONSTRUCTION tENDING AGENCY �
I hereby nffi�m thot�here is a tons�ruUion lend�ng agency for � � � � � � '
the performance of�he work fo�which�his permii is issued � .
(Sec.3097.Civ.C.). . -. . . . .' . . . � .
Lender's Name - � -
Lender's Address '� � � � � �
I certify�hat I have reod�his application ond staie�hot�he ,
. obove informarion is correct.I agree ro mmpiy with all Coumy ���� � � - - -� � �
. ord�nonces and State lows regula�ing Plum6ing,and hereby
authorize represenfatives of this Coon�y to emer upon Ihe � . , �
obove-memioned properiy for inspection purposes. �
� �� ^ � � �� SEE REVERSE FOR EXPLANATORY LANGUAGE .
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