HomeMy WebLinkAbout1707A WORKERS'COMPENSATION pECIARATION APPLICATION FOR PLUMBING PERMIT ya 5�5 � �
I fiereby affirm tho� I hara a certif�oote of conaen�to seff �y,eyq
inaure,or o cer��}iwro of Workm'Compensoron Insuranc¢ CF 817�REY.10iB1�
or^a7 cenified copy ihercoi(Sec.380D.lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ��f �
Po(te`S��O_8�Com �7?4?�
❑ Y Pa�Y� I��GQ
CerHfied topy�s here6y furnished.
QfOR APPUCAM i0 HlA M�GRMT OR IYPE� ���� ^
Certified copy is Filed with the county building inspec- ADORES$ o��'I �S�I ��r p�„reoaz_ Cf�1�3�
lion depanmenl. NUMBER fi%TURE OR I1EM p FEE
��ry i /Y10�/A
Ddf! Appli�ant WAiEp CIpSEi rEAR65i '
CfRTIfICq7E OF E7(EMPTION FRpM WpRKERS' enTH iue CRo55 ST. ,Gq,�iQ �
COMPENSATION INSURAN� ��p OWNER ���
(TRis sMlon nNd not b�mmp�eted if th�work In�elr�d by
fh�p�rmN I�1oe en�himdnd dollars(5100)or����.) IAYATppY
Mnn
I cM�fy�hvi in rhe performance of�he woh fo�which ehia �� �S � ""}��
permi�b ias�red,I shall na emptoy arry person in any monnn �� C�iv �7/�—'�Q'S�T/00/ �
ao as io bacome subiec��o rhe Waken'Companwrion 1,aws. p��p
ODW1RACrOR �
Dote epplicanl QOTHESwASHER q��
M^ilCf irl qpFLICqNT: If,ofrer moking�hia Certlfica�a of SW������
}{N�on, yo� should 6emme subjecl to ihe Wwke�j �� h' `� I i'�' y9��
1....SpBnEOfiOn pMYifi0rl!of IFIE WF1or COdD,YW TuS�fd�111- ISWti SWt�NKlEP CvSrEM C'-QT�`il b S
wne c,ompry wnn wen provn�ons u ��is pv.nif sAan be �A��-- 3 663,6 �ICU�55 Ca7
deemed rekpked. WAhp�qhp ���.�p.
LIffNSED CONTRACTORS DECIARATIQN o6rRicr np ar
I hereby affmm Mw��aro licensed under prwisiorn of Cha�ner 9 GAS srs�FM outlErs ^� �
(cpmrpenurg wi�h Sec�qn 700p)oi Orvision 3 of the Busine» p��ts pyER lO "�'� � ,
andAotesaiom Code,ard my�ece�e�s;�fu�l f«m end effec�. s aEp srStFM oA� VAUDATION Q :
L�mnseiJumber��� Lic.Gass Ca7
OC :
c-,�va�'-+c+�w�� 9-SI-�� e n� o .
onkatla Y Dtna u �
� � I em esempr undn Sac. � 4
N :
I 0.8P.C.fa this reason Plan check fee � �
IDo�e:T_ NJ S
I FLUMBING PERMfT ISSUING FEE S
SignoN�e
ITOTAL FEE ;
I Plon theck opplitont '
S�NGIF FAMIIr
FIOME OWNER�BUILDER DEQARATION Nome
� by uffirm ehnt I am exempf irom�he Con�roUa f Licen�0 q�,�s
t .�or+he following:eoson(Sec�ior.7031.3,8usiness and :., 1 !C, r �.
Profea�ona Code): �;�
❑ y Tel.No. ^' c � �
I,oe owner oi rhe properry,will do the wwk cnd the .
s a��
slrucWre is no�inMnded o�offered fp anle(Ser�ion � .
7044.Bus�nese o�Rofeasions Code). ► I • �I ::�/
CANSTRUC710N LENDING AGENCY - _
1 hereby affirm tha�thers is a consnuUion lendcng agenty iw � , . ' _ ' -
ihe perFormance oi rhe woh for which this pxm��is�saued �•,(�:fi•,.�`:
(Sec.3097.Civ.C.). ,.
le�der's itlama
Le�er's Addrees
I cernfy�fwl I ho�e r�od ihis qpplica��on and s�ate thol�he ► .
abore informo��on is cw�xi.I cp.ee�o comply wirh all Co�my
ordirronces and S�ata lows�egulo��ng Plumb�ng.and hereby �
au�horize rcprasama���es of th�s Cuun�y�o enier upon rhe
abore-meNioned roperiy r'�R ion pu�posea.
SEE REVERSE FOR EXPLANAiORY LANGUAGE
9-Y-d.�
S�gnotwe o1 Parm�vae Date
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