HomeMy WebLinkAbout1706A (10) WOR�as'COMPENSATION DECLARATION � AppI.ICATION FOR PiUMBING PERMIT ya S�S � �
I'hmeby affirm tha�I hcve o cemficata of consent to self �yqyy�q .
insure,or o certificate of Workers'Compensation InsurqMe, . CE 817�REV.IOiEI� � ' -
o.q fa.ifis cr,op�y rhe�f Isec.38op,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �or i3 �
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POol�icy No. Gompa^Y --r—iL . � i
Cenified copy is he.eby furnished.
❑ iOR APPLICANf TO FILL IN(R21Ni OR TYPE) BUIIDING �
Cenified topy i�filed with the touny buiWing impeo ADORE55 0.� L£Y�( Vy�+/ ,Q�.
rion depcMment. � NUMBea ��xruRF op�ihN � fEE I
tocnun
Date Appli�an�-- -. . , wATER QOSEi NEARFST �
CERTIFICATE OF E%EMPf10N fROM WORKERS' BniH iue CR055 Si. � /y , I
C�MPENSATION INSURANCE SHOWfR Qyy�p �
(Thtt+ectlon nwd not ba eompleNd if fh�wetk Invelvad bp ��i .
tho parmlt Is Ior ono fiundrod dollon(i�00)-0�tets.) twVAiORv ADOREsS /5
I ceniiy thoi in the performrnrce oi the wo�k for which�his - � �
_ permi�is issued,I ahal�nof employ any person in any manner SINK [ITY �y 7El-np.$ --
so pe to betome subjc�cl lo the Workgn'Compensation laws. �
�ISHWASHER 50MRACTOR
Dpte applicqnt C10THE5 WASHER ��� .
��r1TICF TO APPLICANT: If, pker making fhif Cer/'rficale of SWIMMINGPOOIRE�P70R
-` �ption, you�should hecome zubjx� �o rhe Wak�rri -
S
_ Penaation provisions of tffe tabor Code,yo�musf fo[Ih- �,qyyN$pRINKIERSYSTEM Gltt C,0 .NO.
��with comply witA such provisiorn or Ihia permit shall be STpTE /
deemed reroked. � - WA7ER HEA7ER ��NSE NO. l�� CIAS3
�IC�NSED CONTRACTOIiS OECU4RATION qSTRKf NO. � BV
I hmeby affirm tFq1 I am licensed urder proyiaiory of Cfwpter9 �S�T� �T�� ' '�
(mmmancing with Sacrion 700D)of Dirisiqn 3 of the Businca p��pyER �o > �
ard Rofeuions Code,and my license is in fyll forro and effep. 5 PER SvSiEM� FINAL VALIDATION O I
�a�63� �+.�� oA,� � �
Liceroe Numbm Lic.Uma_�_G__�_ � . p� �
`-�}�ttvy �,,��vASe�'9p�L't+�c
. FINAL O �
Conhactor y Dab 9``1—FL ev � '
❑ V �
I am eaempf under Sec. y i
s.aa.c fo.,ti�s reaso� Plan check fee Z '
Duee: �
PIUMBING PERMIT ISSUING FEE S
Signvlura �
. � TOTAL FEE � .
Plon cFeck opplimnr �
SINC>lE FAMILY !
HOME OWNER-BUILDER DEQARATION Name � �
�� by affirm rhar I am exempl 6om the Conhqtfor'c license �`f.� ?0,b Fi �
� �or the following remoo(Section 7031.5,Buainess end Addross � • � . . '
Wofeseions�ode): � � City Tel.No. f • • � • •5
i
❑ i
I,ae owner of rhe proper�y,wiil do the worlc and ehe , r� •1 Q�C
struct�re is no��nte�ed w offered for sale(Sec�ion , .
7044,Busineu and Rofessions Code). � . �? d ��J�u �
CONSTRUCTION LENDING AGENCV � . _ ��
I hereby offirm ther the.e is a conanucrion lendiny aqency for . G�Q d=G� '
fhe perfamance of rhe work for which this permit is issued . . �
(Sec.3097.Civ.C.). . .
lender i Nome ' . �.
Lerder's Addreas I
I cx�ify thot I Fave reod rhts applko��on and sMte that the . , � -� �
above infamation is correct.I agrce b tomply with all CouMy � ,
ordinonces ond Siaie lows regulating Plombrng,and hereby •.
authorize repeaenrotives of�his Couny�o en�er upon the !
above-meniioned perty for'ns purposes.
SEE REVERSE FOR EXPIANATORY LANGUACE
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