HomeMy WebLinkAbout1309A (7) ---1
WORKERS'COMPENSATIONDECIARATION APPLICATION FOR PLUMBING PERMIT '
I hareby atFirm thof I lqva o cenificate of tonsent to self �bqbyq � i
inaure..or L certifimfe of Workers'Compansorion Inwmnce. CE B�7(REv.t0iei)
or o ce«�f��ed��co�py�rheCre��.3800,lab.e.) COUNTY OF tOS ANGELES BUILDING ANd SAPETY '•
Po❑licy No.N._S�L�Com�pony r M �� ' ; i`
CMified copy is heroby fumished. '
OFOR APPLIUNT TO Fllt IN(PRINT OR TYPE) ADDRESS 1 , � . i
CpAified copy Is filed with tha cOu�ty.building i�spec-
�iondeparrmant. � NunneER F�Mu�at�M- � F� �TM Qi2m !
Date� Appli�cnl wATER CIDSEi � �� �
BAiH 7U8 2, � CROSS ST. i
CERTIFIG4TE OF E)(EMPTION FROM 4YORKER$' . - �
COMPENSATION iNSURANCF �Ep owr�e 2i � �
(This sMton nNd not b�sompl�lad if Ih�work invoWed 6y ,Nqu '2 „ 1� �
fho p�rmk Is for o�n hvndrod dolltrn(SI00)er(s��.j lqvnio�tr Z . qppRE55 7 fi
I eenify rha��n�he porformance of rha work fw wfiicN�his �
permi�is inued,I ahall no�employ ony pmso�in any manner 51NK �/f� GITY M TEI.NO.'����� �_
— so us�o become aubject fo the Worken'Compenwtion(�ws. aS�twASMER ",�y �p�qRp�/�, �O� � ,
V� �� i
Dqte PlicaM QATHES WASHER r n . 1
���1TICE APPlICANT: If. after making this Certiflcate �� L' � G� `� 'I
� �ption, you should become subjec� to�Ihe Workers' S1N�MMINGPOIXRECEROR ;
'a..npenw�ion provisiOm Of��+e lOba Code,You musf forth- LAWN SPRINKIFN 51lS�EM C{�O �� �.�. +
with comply '�h euch povision>m rhia permit ahalV be STi���.f '� . � � -36 '
deemed ravoked. � WATERHFAIER ��T ;
IICENSED CONTRACTpRS DEGW RAt10N � oRttt�c7�04 PRo�SSED er
I lierekly affirm�FM I am litensed undd proviFiom ofGhapYer 9 �S SYSiFM OUTlEiS �j v / {
(tommencing wiih Sepion 7000)of Dirisiqn 3 of the Busi�ss pUTLEiSOVER �� y i
and Rofess�o�s Code,and my licensa ia�n ivll#Qrce qnd eNqct S��� DAiEL / o j. VAII ATION . � �
license Number 443`�7y �ic.Clnas3� �� / �� V !
fINAL �
COMraNa.���1�Data� - BV � o i
❑ I om ezempl�mder Sec. V '
W
d �
N
s.sr.c.fo.rh�s.�o� pian check fee , Z '
�ta� FIUMBING PERMIi I$$UING FEE E O -f
s;9�p7�0 TOTAI FEE �i �Cl 9 A '
P1an check opPlicom . . . . �,' � '• '5
SINGLE FAMILY •
HOME OWNER-BU4DER OECLARATION � Nvms�. . . . � I + •��:5 O
yeby affirm nc��I om exempr from rhe Controaa a License
1fo.the follpwiny reawn(Sec�on 7031.5,B�siness and �d� - • •4 4,J U�. j
~F:ofeasioro Code}: ���y Tel.No. •� ;
❑ �,as owner ot�ha property,will do the work 9nd Ihe . � �" - D Z� G"8� �
atrucrure i�not intended m oHered for aale (Sectfon � '
7044,Business and Profess�ona Code). � . � � �
CONSTRULTION IENDING AGENCV � � � � � �
I hqreby affirm rhat�hera is a consnuc�ion lendin9���Y� I
fhe performance of the work for which this permit is fa5ued _ . � --- - - - �
(Sec.3097,Civ.C.).
i
Lende�a Name '
Lender i Address I
I mnify thot I ha�e reod this oppliwtion and stara that rhe ► � j
a6ove infama�ion is corrM.I agree to comply with ail CounN
ordinances and State laws rag�laiing Plumbing,ond hereby � '�
oWhorixe repreuntativas of this Coumy�o enter upon the - " � � , �
a -menliooed prop Ny fo�inspeuion purpos s. �
r . �� SEE REVERSE FOR EXPLANATORY LANGUAGE ;
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