HomeMy WebLinkAbout1480A (8) � i
- WORKERS'COMPENSP.110NDEQARATION APPLICATION FOR PLUMBIN�G PERMIT . y�G2.
I here6y affirm that I have a certificate of conseat to self , �bq�q - �
insure,or o certifimTe of Warkers'Compensatio Imuwnce. Q 817(REV.10/81) . . . . . . � �
or a cer+�'e$}�o��+epaf(Sec.3e00.4ob.e.) � COUNTY OF LOS ANGELES _ BUILOING AND SAFETY �
Ys
Dolicy No. Campony 'T ��. � .
�enifiad copy ia h�mby fumished � + .
❑ POR APpLKANT TO fIU IN(PRINT OR TYPE) eU�� 7� ��-r�
Certif�ed copy�s flfed wlrh the co+rny buiiding inspec-
��ion de ment. . NUM9ER PrMURE OR ITEM � - FFE ��T, .
DGta ✓� -� APPli,ront . WA7ER CIASEf � ?~ � - j
GERT FICATE OF QXEMPTION M WORKE ' BAD+TUB . `"""""'. �� `S �RaY'� � 4aMY� '
CQMPENSATION 1NSURANCE S��Q OWNkR � (
(Thq r�ctlon nwd no�ba eempl�Ird tf/ho werk�nwWed hy
fha pormi!It for one hvndrqd del(an tS100)er(ets.) WVaiORr �� � .
. I canify�har in ehe performance of�he werk fryr which�hte �� � � - ;
permit is isxred.I aholl nor employ an�r�person in�anp manner � 6INK � Cn1'� - - �8..ND. j � :
io m ro becoma wbjart to the Worken'6ompenaelion laws. ot5HwA5Hee - - tpMpq�Tpp � �, � i
pdfe o�p�icanl . � CtOTHE5WA5MER .�� a . ;
NQTICE TO APPI.ICANT: Ifi, dhe� makir1g rhis�eAlfltafe of �������� �
Exemptian, you sho�ld beeome ne6jeer �o �he YVorkers' � Tg,r.�p,
Cwopenwtion prorisiom ef�ha lobor 4ode,you must forth- �,qWiySPR�N�ctERSy$tEht . f , j.�.�
with compiy with wth provisioM ar thi�p�rmil ihctl be _ _ SfAIE �. . � UC ��[ , �
daemed revoked. � . � . - WnifltNEniER�� , � � �Y 1
UCENSFD CONTRACfORS OEGLARATION P cE55ED BV �
. I fi8re6Y affirm thol 1 am Iicensed w�d.er prwisiom of paprer 9 OAS SrSiEM OUTLE7S � �R - � .
�mmmenc��g wuh Seaion 7000)of pixis�an 3 af the evs��ess oun�rsov� f�Nq� VALIDATtON ,
.and Profatsions Code,and my licenx is in(�II force unQ effM. S PER Br57EM � / O l;
LiceroeNum �� ��O lic.Cloas �T � .. . � RAfE '"/�` . V S
FINnL �� ��O� O 1
com�«,a �v �z oare 3t1 3 eY ti• • , •5 v ;
�. I am exempt um�x Sec . . . . . ' ' • y i
'� • •3Q50 �, i
B.BP.C.for this reuson � � Z
Plan check fee ► • , a�`,�C� +
�e: PLUM8ING PERMIT ISSUING FEE S � � �'� ' � 1
Sigrwture __ . Q�j� Cl—'��l i
70TA1 ffE -'jj ,
- . Plan check applicant . . . . �
SINGLE fAMIIV .. . - {
HOME OWNER$UIWER DECIARATION - Nrnne - � - � � � . . _ �
I hereby affirm that I am exemp�from the Conkec�pr's license p�d�s . . . �
Law for the followiog reason(Seciion 7031.5.Bvsinets o� �
{
Rofessions Code): City Tel.No. � � - � �
❑ I,rn owner of�ha pope.�y,will do rhe wak ard�he . � . ' . . i
sfruMure is�inteMled or offe�ed for spla(Sec�ion - . _ . . . �
7044,Business and Profeasions Cade).
CONSTRUCTION IENDING AGENCV � � - �� � � --
I hereby cffirm that thme is o conshudion lending ageMy fbr
Ihe performance of�he work im wbieh rhis permir is iuued . . � -� � � - ��- �� - � � �
(Set.3097,Civ.C.). , - � '
i
� Lender b Name � �
Le'Kler's Address - . . . . . . ._ . - i
I certi(y iha�I have reod�h�s opplicarion and sro�e�hai�he . .. .. . � ;
abore informa�ion i caract.I agrea ro comply with all Goynry �
ordinances cnd S �aws regulafing Plumbirg,ond hereby � i
aothpixe ef0 lives af this Counly b enler pon ihp . . . . . ..- . . .
above-m ti ed roperty for ins �ion purposea . �
SEE REVERSE POR EXPLANATORY LANGUAGE .
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