HomeMy WebLinkAbout0885A (4) WORKERS'COMPENSATIONDKIARATION APPLICATION FOR PLUMBING PERMIT � ;
I hereby pffirm rhat 1 Mve o ceN�fica�e of consent to teli �6qyy�q
insure,w o cer�ifiwfa of Waken'Compeneation Insuwnca, Ce ev�rtEV.i0ie�) � - -
• or a eernfed copY thereof(Sec.9800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
F�olky No. Company . - .
Certified copy i�hereby furnished.
QFOR AGRICANT TO FILL M(PRMT OR T'PE) 8���'
Cenified copy is filed w�th�he counry b�ilding inspec• ��
tion depaAme��. NUMBER HXTURE OR f1FM �� FEE ��T,
WATER ClOSEf �
Dma Applisont � � NEARESi � i
CERTtFICATE OF EXEMPfION FROM WORKERS' eniH iue ��• �
� COMPENSATION INSURANCE SHOWER OWNER � ��
(Thts s�ceton nNd ne1 bs eomplel�d fFths vrork involred by �
th�p�rmlt 1�for ona hvndr�d dollaq(SIOO)or Ins.) wvniORv �� �
ADDRE55
I certify thp�in Ma performance of the work for which this
permif is issued,I shall nof em ony peraon in any manner �� GTY TFL.NO. �g l
� so as to become su6jecf lo th Wo eri mpensotion low. p�WPSf�ER j
CONYNAC70R �
Oote pplicon C10THE5 WASHER �� i
NOTI TO A ICANT: 1{, after making lfila Cenlficate of � �
Exemprion, yo� s�ould beeome su6jeU lo the Workera' 5����'���� GTr 1�.w0. {
Compensation provisiorts of tha labor Code,y0U muat}orth- �qyy�.��MKIER SYSfEM
with rnmply wifh auch prwisiona or this permit 4tw11 be � STA7E . l�C.
deemQd revoked. � WAIERHEAiEII ���� ��
ucavsE�coNrnncroRs pEC►�+RAnoN asreia nro. rRoc�ssm ev
I hereby affMm tFa�I om licensed under prov7sioms�Chopfm 9 ��5�� �� - �Q �
(commenciny with$ection 700D)of piuisiqn 3 of Ihe 8usiness pUitEtS py¢R . .- . y ;
ond Profeuions Code,and my licensa ie in full forte und effecl. 5 PER S'S1EM FINAL VALIDATION 6' '
Licanse Number lic.Claa ' �A� V ;
. . HNAL � . � .
Contractor Date . BY � '
❑ �
1 am e.emp�w�der Sec. d i
N i
B.6P.C.for thin reason - -- - � � � 7 q
Plon ckeck fee �
oote: '� �
PI.UMBIN6 PERMIT ISSUING FEE S �
Signoture � .
IiDTAI FEE ;
Clan c4�eck opplicpnt �I
SWGLE PAMIIV � /1 s'0 8�a 5 A �
HOME OWNER-BUILDER OECLARATION Noma ��. (��/ •5 .
�hereby oNirm thof:am exempt from the Conhxror's L'ecense �'� k,••' • '• ;
law for the following reoson(Sed�on 7p31.5,Bvsiness and ��� '
Profesaions Code}: ` � •-•2 Z,�J� �
QCity Tel.No. ,
I,as owner of rhe prope.W,will do�he work and the � � � �• • •2 2 5 Q= �
shuduro is no�Intended or offared for mte(Section . . . V !
70�4,Business ond Professione Code). ... . \ 0 b 2 1 —8 5 �
CONSTRUC�ION LENDING AGENCY � '
I hereby affirm�haf there is a carohuction lending ogency for � � � i
the perfwmance of the wo�k for whi�h ihis pBrmif is iESVed � ` � �
(Sec.3W7�Civ.C.). � � ���V 1
Le�der's Name �
Lender's Address '
I rorlify that 1 hove read this applica��on and sM�e thal�he ► - .
obove information is correct.I agree to comply with al�County ,
ordinances and State Iaws regulating PI�mb7ng,and hereby �
orize represenmtives of this Coanty ro e�ter upon�ha �� � � � -
bov -mention propeny for i cNon pVrposes. � � �
SEE REVERSE FOR EXPLANATORY LANGUAGE
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