HomeMy WebLinkAbout1765A (10) WORKER$'COMPENSATIONDECLARATION qpp��CATION FOR PLUMBING PERMIT �
I hereby offirm that I hove a certificate of consent to self �yqyy�q
inwre,or a certificale of Workers'Compensotion Insurance, CE 817(REV.10i81) . .
o�e ce���cop i=eof Se.���00,�b.,C.)��p /� COUNTY OF LOS ANGELES �BUILDING AND SAFETY
acy o. Comp b�J�!L.LY/'�! .
Certified copy is hereby f�rnished.
FORAPP�ICANTTOFI��IN(PRINTORTYPEJ BUIIDiNG G / ^
�Cerlified copy is iiled wi�h Ihe coun�y building inspec- ADDRESS ���� �,J +(�.�(l7 � �
tion de o�lment � NUMBFR FIXTURE OR ITEM r@ FEE �
1 � ��j-�/y �f LOCAlI7Y �
Dale�_Appli[anl � �✓�+TERCLOSEf NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' � BniH iUe CROSS 5T. �
COMPENSATION INSURANCE � OWNER -G
(Thls s�ction n��d nof b�compl�t�d il fh�work Invelv�d by SHOWFR
tho p�rmit fa!or ono hundnd dollon(SI00)or lets.) lAVA70RY MA�� C7��J 1/}
ADDRE55
I certify that in the performonce of�he work(or which ihis
_ permit is issued,1 shall not employ ony person in eny manner SINK CIN �"`�` TEL.NO.�'-�� �
so as�o become subject io the Workers'Compenwtion laws. piSHwnSHER � ���
CONTRACTOR r
Date - - Applimnl CLOTHES WASHER qODRE55 �LI�i� ( , e
NOTICE TO APPLICANT: If, afte� moking this Cerlificate of V
SW IMMINC>POOL RECEPTOR
E:emption, you should betome su6ject to ihe�Wo�ke�s' a
CITY I TEI.NO. //
COmpa�Sa�ion provi5io�5 of Ih@�obOr COde,yOV musl/Orih- �AWNSPRINKlER5V5TEM •
with comply wilh such provisions or this permit shall be SiniE //� � liC. �" '—�.
fJ9emefJ feVokBlJ. WqTFRHEATER IICEN5EN0.�� CV+SSL.J•^�^'
IICENSED CONTRACTORS DECLARA7ION DISTRICE NO. PROCESSED BY
I hereby offirm�hot I om licensed under provisions of Chopter 9 GAS SYSTEM OUIIETS
- (mmmencing wiih Section 7000)of Division 3 ot�he Business OUitEi50vER
� a�d Professions Code,o�d my license is in full force and effect. 5 aER SvSiEM FINAI {/A ATION
7� /� --�'� DATE p O
L�cense Number�3�J lic.Closs��/ � �o
(���'K�.L� l��o� BY AL U.
Controcro� �a �
❑ I om e�empf under$et. ' �
B.SP.C.for this reason , W
Plan check fee y�
Daie: � pWMBING PERMIT ISSUING FEE S "� �Q 5 A Z
, Signalure #� • • • •5 ^
TOTAL FEE ��� � � �F�
. .. . . Plan check oPPlicdnt � s • 1 �5 O�
SINGIE fAk!IlY �
HOME OWNER-BUItDER DECLARATION Name - O�.O H—ES'I �
1 hereby oHirm fhof I om eaempt from the Contrvcfor's License AddrPss �
Law for ihe following reason(Seclion i037.5,casiness and .. . .
Professions Codej: Ci�y Tel.No. �
❑ I,as owner of Ihe property,will do ihe work ond Ihe � � �
struclure is not intended or ofierad fof sale (Section �
7044,Business and'Prafessionz Code). � , - - � - � �
tONSTRUCTION LENDING AGENCY ,
I heraby afiirm thot there i:a mnstruction lending agency for - � � � ,
the performance of rhe work for wh�ch�h�s perm�f is issued � , �
(Sea 3097,C�v.C.). . - - - - - � . . .
Lende�'s Name � � ' � �
lender's Add�ess - � - � � " � �
I certify ihot I have reod this opplimtion and sto�e thot�he ►
ahove informaiion is correU.I agree�o mmply with all County • - - -- � �
ordinonces and S�afe lows reguloiing Plumbing,and hereby
oothorize represemotives of this Coumy to enter upon ihe � � -
obove•mentioned prope�ty for inspection purposes.
� �� ' � � � SEE REVERSE FOR EXPLANATORY LANGUAGE
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