HomeMy WebLinkAbout1716A (10) WORKER$'COMPENSAiION DECIARATION qppLICATION FOR PLUMBING PERMIT ya s�s �]
I'hereby uffbm�ha� I have o can�fica+e of consem ro se�f �yqyy�q 15
insure,o�a certif;core oi Workers'Compenm�ion Insuronce, fE8�7�rsEv.toi8i�
o•,��ua 5�n 4 I(gec.3800,tob.C.) COUNTY OF LOS ANGELES BUIL�ING AND SAFETY �"[' '3i](
P❑olity No.�mpo^Y �rT� �'�^/� "
Ce�hfied tqpy is heroby fumiShed. y' �t-
QFpq APq,ICqNT TO FILL IN(RtINT OR TWF) BpppRE55 �yy a8 �"���Cry�£ :
Cer�ified copy is f�led w�th the eoun�y bu�ld+ng�nspec- �Of��
�ion depanmeM. NUMBER NxfURE ON�7Fnn � FEE ��m
Data Appti�on� WA�ER QOSE7 NEAREST � `
CERTIFIG4TE Of EXEMP110N FRQM WORKERS' ��7UB ��' F � ,
OOMPENSATION INSURANCE ��p OwNER
(TMs sMion nNd no�b�rnmp�d�d ff th�work Imolwd b�
1ha parmlt is fer ene hvndnd dellan(=100)m�oss.� �qvarORr Aoort�ss �. I 5 1 .
I cernfy�ha�in�Ae pa.formo*�ca o}tha wo�for which rhi�
p9rmil�s�saued,I�hall no�emplw orry pcmon in any monner 51NK GTY { El.NO. .
so aa ro become subjM ro rhe Worken'Cvmpensaeion lcws Di5i1W7�SMEY
CONTRACTpp
��
pot6 ePPr��� C10TME5 WASHER �� �
`"��TICE TO APPLICAN7: If. after rtqking�hia�errifimre of ' .
hw��. rou Shwid become subjM ro �ha Workeri SW�����
fipenw�ion prorisiom o4 ehe lobor Gode,you musi fonT� !AWkSPRiFCc�SKTEM GTY ea� � 3p 1EL NO. J y —��
with camply with such pmisiona a lhn per!n+t shall bo
I deemed re.oked. wAiER�i�e '�t�w5e tr0 3 C�iass e �
UCF1V$Fp CONiRAC1�RSDECtARAUON qsrmcr No. Br ,
I herpby eHirm Ihol l am licqntqd urdOr provi�om of Chopter 9 G�S SVS7EN W t1F15 \ O r
Icvmmmx�ng v�n+h Seaion 7000)ot Ohhion 3 of�he Busi�� q��py¢p '
ond Profegsims Cod.q.and my license is i�full force ard eHeu. ��S�� fINAL a
VALIDA110N O �
l�ceme Number���� }ic.Ciqas C 1� OATE V .
Y
F�avw� �C•*�vala'4"�;�"�q-y-dL fB1YNAl O
controc�w
❑ i am exemp+under Sec. . W .
6.
N
s.ar.c.ro�rti�s.saw� Plan check fea ?
pnte: RUM@ING PERMiT I$$UING FEE S `O
S�gnatu�e TOTAI FEE ��p �
I Plan check appl�cant '
SINGLE fqMllY
I HOME OWNER$U1(DER pECIARATION Name
�by aHi.m�ha�I am eaempr(.om tV�a Corrtrana'a licarne ��a
fm the following reason(Sec�ion 703i.5,9us�ness an[j
Wofess�o'n Code)' C+�y Tel.Pfo.
❑ �,m owner of�he p�oper�y,will do M�e wwk ond�he
struUurO�s nol interded or oHered for snle(Sec�ion ,
70Ia,Bus�neu ond Protess�ans Gode). ,
CONSTRUCTION IENDING AGETKY ' I ! I.C:^ ,
I herebY o�firm thot�hme is o conmuction lending agency ior . . a a a '.
the performance oi�he work for which this permif�s�ssueQ � "
(Sec.3097,Civ.C.�.
� .. .� j f.J il �
Lender'c Nome s � .i j :�.,. .,
Lender"c P.ddress � ,, �.1+—'.�:: .
I cen,fy�ho�I Frove�ead rh:s opplica�ion and:m�e iho�ihe ►
abora Infama�an is carecr.I agree to comply with all CouNy
o�d�nancas and Srate lows regulol�ng Plumbing,and hereby
authori:e rep�esenta��ves of this Co�niy W enter upon�he
above-mantioned roperly fo�in c�ion pu�po�es.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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