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WORKERS'COMPENSATION DECIARAIION APPLICATION FOR PLUMBING PERMIT ya s�s
f hereby 8ffirm Iho� I houe o ca��ificale of consent ro aelf ���q
�nsuro,w a cerlificole o(Workeri Compe�sa��on InguroY�te, CE 817�RFV.IOiBi� •
o�c�ars Sg�h.�of�sec.380o.Sla,rb�C�� ���Q COUNTY OF LOS ANGELES BUILDING AND SAFETY �T .� '
P�olicy No. Compuny
Cartified copY i�hereby}urnished.
❑ ipp APPLICANT TO FILI IN(PRMT pq TYPE) BnDDRE55 /� � �
Cenified copy is filed w�th ihe couniy buHdinq inspec- ••l �
tion deparfinenf. NUMBER HxtURE ON RFM � FEE
WCALITY ���/U �
WASEp CIObEi
DO�e App��Ga�� NEAREST I
CERTIFI(ATE QF E%F/u1PTIQN FItOM WORI�RS' 9niH iuB [ti055 ST. �e�9n/O ,8' 1
COMPENSATION MSURANGE ��p qwNEa
(Thh sMlon nwd not b�complN�d if th�work in�o�v�d b�r �x
fha p�rmiT A for on�bandnd dellan(SIQO)or b+s.� Uvaiatr DDitt5S S : �
I eenify�Fq�in rhe performanea oi�he worh for wh�ch fhis
Permil i]i»ued,��hall nol empfoy any permn in any mOnner y^� C��v�
so m ro become wbjec��o'he Workera'CATpe�ofion Laws. D�SF1WA3/1EI1 _/
CO�rtRACtOR N .
pplp e�.+limnt 40THESWASN�R .
��nTICE!O APPIKANT: If, o(re.mak�ng �his Cerrifimro of #�'s 9 S
.�fmn, you ahwld 6acome aubjacr ro rl+e Wprkers' �����R���
nlallon plorifiOrl�oi ff1B lGI�Code,yoV m�l110A)+- IAYYN SVII�NK1fP CvyfM ry� �Y � /� � �C
�xitF. :,pmpl�� v:ith yrch pro.;yiw�s w iY�is pe[mii ahaii be V SiAiE !K. �
deemed revoked. waiEp MFqiEp Gc�wSE�+0.�0 3 Un55 �
LiCEN,SEp COMRACTORS qE�IARA�IpN asrrtirr wo Br
1 hCreby atfirm thot I am lice�ted urder provitwnioFGhop�er 9 GAS Sv57EM OURE75 ,O ;
�commenc�rg wilh$ecticn 7000)of Oirision 3 ot�}�p Bvsineas pUitE75 oYEx . �'
m�d Aofesaiom Code.and my licensa if in 1�11 forea nnd effecl S ofR Svg�M �F1NAL � .
I 3��� �;�.aass G'27 �ATE VALIDATION � :
liclnse Numbar y� �
�ijf�yyy �r �.� p FINAL O
� Comrocro.�9"�� , t�r•a G"�^� �Y V :
I � I om eeempl V�der Sec. �
( B 6P.C.ior ihis reoson p�an�heck fee � Z
Ome:
PLUMBIIVG PERMIi 155UING FEE f
Sigrq�ure - — �
� 70TA1 FEE I S
%an check appl�conr
SINGIE fAMILV
HOME OWNER�BUIIDER OECIARATION Name .
' {eby o�firm�hot I om axempi from Ihe Co�hot�or'c licenf0 ��s ry
/fa tM follow�og reuson(Sarnon 7fq�.5. Busi�ev and - � ; �.�". .
Rofessioin Code}: Ciy Tel.No. '
❑ I,oa owner of rhe pvperry,w�ll do�he work ond thq ' � � � �` 1
ahuNwe�s no� inte�ed a offe.ed for sale(Sed�on �
7044,Bu�nns and Ao4essions Code). � ' " � F���' ,
CONSTRUCTION LEN�ING AGENCY . c � o '� ;' �; _ '
I hereby afinm tha��hero is a conavuction lend�ng ogency fa �
the pe�formpnca of�ha worii fw which�his permit is issuetl , '%I`�(,'•=� ,
ISec.3W7.Civ.C.). .
Lendx i Name � �
lender'c Address
I cernfy rhat I hove read this apO���o��Q^and atote thar ihe ►
abova in4amallon is carxt.I agree ro comp�y wi�h all Couny
o�dinonces and Sto�a lows�egular�ng Plumb�ng,and he�eby
authorize �eprexMa�ives o(Ih�s Coun�y fo en+r upon�hp . °
above-menNoned rt #or� n purpoaes. �
SEE REVERSE FOR E%PLANATORY LANGUAGE
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