HomeMy WebLinkAbout1837A WORKERS'COMPENSATION DECLARATION qpp��CATION FOR PLUMBING PERMIT� �'l {� �
I here6y affirm thot I have a cerrifico�e of consenl to self �6qyb�p I i
insure,or a certificate oi Workeri Compensalion Insurance, CE 817�REV:10/81� . � - Ll
or p,cer�iiied copy�hereot�Sec.3800 lob.C.) COUNTY OF LOS ANGELES / BUILDING AND SAPETY
P❑olity No.�ompony�Z�iY1�°..r5 y G S� L 7— 'c :� .....-��.�
Cer�ified copy is heraby furnished. �
FOR APPLICANT TO Fltt W(PRINT OR TYPE) BUILDING
� Certiiied copy is filed with�he couniy building inspec- ADDRE55 1 y . ���u+h ��L�`�� v�e.w
lion d�parlrt�Qen/t.� y^ NUMBFR FIICTUREOR ITEM (d FEE � ��`��,
9 g/O'�+ ��1•�. P1umbJu�! � WATERClOSET �1 �� �
Dale Applicant NEAREST ,• �
� � CERTIFICATE OF EXEMPTION FROM WORKERS' J BATH TU8 A.ti CRO55 5T.
COMPENSAiION INSURANCE SNOWER V" owN� � -� G �
�.'� t'�s'
�(Thb��cfion nNd nof b�eomplabA If Ih�work�nvob�d 6y �y�� � �
. �h�permif I�lor on�hundnd dollon(SI00)or Ins.) tAVAiORv 24 oa A�REu .�A��� � ��. .
I certify that in fhe periormance of 1he work for which�his
permil is issued,I shall not employ'ony person fn ony monner SINK . � CITY �, M ('� TEL.NO.g�'� _
eo as lo become subjecl to the Wo�kars'Compenso��on Laws. DISNWASFIER � �
�ONiRACTOR p u
� Date �� � 6pplicanl CLOTHES WASHER � A�R� , /��
`'�iICE TO APPLICANT: It, afrer making lhis Certificote of . �•'
Fption, you sliould become subjeU to the Workers' SWIMMINGPOOLRECEPTOR
_fSpensation provisions o�the lobor Code,you must forlh- ��T� Q(' TEL.NO��—8C�
LAWN SDRINKIER SYSTEM
wifh comply wilh suth provisions or �his pe�mit shall be STnTE �l l�C. ^ -
deemed revoked. . waTEtt HEateR uCENSE NO. y 7—!� C1n55 l�'
IICENSED CONTRACTORS�ECIARATION . � DiSTRiQ NO. ESSED BY
I hareby aHi�m rhot I om liceneed onder provisiona of Chapter 9 GAS SVSTEM OUREiS �
(commencing with Seclion 70W)oF Divis�o�3 of the Business - OUT�ET50vER �
ond Professions Code,and my litense is in full faca and effecl. 5 PER SVSTEM FINAL VqLIDATION �
�1y3—���,l (�� �� DATE 3,y t,7 i�:
License Number Lic.Closs3�� O'
q FINAL U I
ContraUor ��• Do�e ` � BY . �..
❑ O:
I om e�empt under Sec. V
B.&P.C.for this reoson w i
Plan check fee , o-�
Date: ��
PLUMBING PERMIT ISSUING FEE f O SO Z i
Signo�ore �
TOTAL FEE �
- Ptan check oppticant �
SINGLE FAMIIY � �
HOM£OWNER-BUILDER DECLARATION Name� �� � � �
i
' �`�yy a{firm ihai I am exempf from the Cantratlor's License qddress •
� j(or Ihe(ollowing r wson(Sedion 7G31.5, ousiness and � � " " " � � .
Piofessions Code): Ciry Tel.No. .
, ❑ I,as awner of ihe property,will do the work and the - c?� 8 a']A �
structore is nat inrended o�oifered for sale(Section �
70a4,Bvs�ness and Pro�ess�ons Code�. � n • • • e •5 i
CONSTRUCTION IENDING AGENCY � � � I • �O Q S O
I hereby nffirm thal ihere is o construction lending agency for
�he pa�formance of the work fo�which ihis permit is issued . . .. . _
(Set.3097,Civ.C.). •' � �n.5��
OQD9—Sb
Lender's Nome �,
Lender's Address
I cerfify ihor I hove read+h1s oppl�caiion and sio�e iha�the ► .
obove iniormotion is correct.1 ogree to comply with all County _ .
o�dinon s and Stote lows regulofing Plumbing,ond hereby � �
oat e epresen�a�ives i this Coonty to enter upon the � � , �
o e lioned pro r (or inspection pur ses.
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