HomeMy WebLinkAbout1093A (5) I WORKERS'Cn.NPENSATICN DECLARATION APPLICATION FOR PLUMBING PERMIT
, I here6y,offirtn�hol I hovr.a cr.rtificote o(consenl�o sclf in- ?�M75 C�\Y n�e7 n
.AAGp�1
•Sure,orn cr.ni(ico�e of Wcrkers'Compensa��a�Insuronce,cra [E 917(RFV,8�86) I 1
ce.ti(ied copy ihereof(Sec.3800,lob.C.) L.1
�`,nlicy No. ComWnny COUNTY OF LOS ANGELES DEP7.OF PUBLIC WORKS
a CPr��fted copy�s hereby furnlshxd.
FCR AFPLI�ANT TO Fi�L IV(:�.NT C4 TVPF.) P.U'lC�M1:G
� CerGfiedropyisiJedw�ih�hecoun�ybu�ld�nginspec��on �CDce55 z�� f [,(� �
dapnrrmenf. � NI;MBE4_ fi%iUP�C4liE'.1 .r' F" LCCALITY �r
1YnTER ClOSCT ITO'[ET� A
Date Ap�licanr CRASSSSi. h4 v �0(.7
CERTIFICATE OF EXEMPTION FROM WORKERS' R�.i��iU!i " �
COMPE�SATION INSURANCE n����`R A^-'
SF�OY:�R I — --� GHY�-N—�
(This�eclion na�d not be complet�d iF�ha work tnvolved by .�;,q n .
fh�pvrmit i�for ona hundrad dollo�s(5100)or lett.) LAVATpRY I aD^:ESS� /J�✓/� L.(�
I cerlify Iho�in thp perfermance of Ihe work fer which Iti�s�er- p
mii is iss�ed.I sholl not employ ony pe�so in an manner so � S:vK G U7� Ciiy rt�'np S6D�0
os�o bec me subjecl in�he Worke�s'Co pe�sorion Laws. D�SH:^/A51+C�' �p �'���
�'CN7R�CT02 /���n
Do1e e � �Applimnt CfOTl+CS\VASNER I aDCCESS
NOTICE T AP ICANT�Il,ofrer r�oking ihis Cerhfimir,of Ex- � "
em �ian, ou should brcr,me sub'ett to ihe Workrrs'Com on- 5\VI5'.11'NG POCL FfCEPTCR
P Y I P�� i C:iY . TiL.N'J
solion p�ovisions oF the La6or Code,you mus�Icrthwith romp- . ,,,,.„�•.;K����y;-�;;,
ly wi�h such provisio�s cr this permit sholl be deemad rr,vo4- �� " ^ SiAii LIC.
ed. WATER 41EATER I L'CENSE��0. CLA55
LICEN$ED CONTRACTORS DECLARATION D!5:ICT Np. FaCCfSSED 6Y
I hxreby offirm!hat I am licensed under provis�Cns of Ch�p!er GAS SYSTE.'.� OU7lET5 )�
9(mmmnncinc�wiih Settion 70pp)01 pivision 3 oi�he Bus�ness CUIlEIS OY[R I - �
ond Piofessions Codc,end m licenxr.is in full forrr.r.nd ef- 5 PE+SVSiE�.�
Y FINAL VALI ATION a
feci. I OA �
License Number Uc Class I � V
FINt. a
Connador po�e � BY �
� I am r.xempi under Sec. I W
a
B.BP.C.Icr this reoson Plan check fee , y
2
� �O�P� PIUMBING FFR.MIT ISSUING FE�5 �D IS �
S�gno!ure TOTAL FEE �' .
SINGtE FnI.+.IIY plon check appl�cnnt
HO"PE OW.NER-9UIl�ER CECtARATiO'J
I hereby offirm thot I om exempl irom the Conlrac�or's License Name A,� Cj���
Law(or the(cllowir.�rcason(Seciion 7031.5, Business on<i -- �_� �,�,_; ,
Arcfessions Codr): A�ldrrss •- � � ���� '
� I,as owner of ihe preperty,wili do ihe work ond ihe �'�Y 7c1.Nn. �• � • • ..
slruc�ure is not in�ended or o(fered far scle(Sec�ian 7044, , � � •
� Business and Professions Cede). ► � • •�!.::(;
CCNSTRUCTION LENDIhG AGENCY s , ��-7,;;�;;
I he�eby oifirm that there is a censrruc�ion lending oqr.ncy(or �
fhe performa�ce of the wo�k fo�wh�ch this permil is issued � ��G�'—2.:(S
(Set.3097,G�.C.�.
lender's Name
Lender i Add�ess ' �
I certify�hal I have reod lhis oppllconan and siote rhol the ' .
above InFor ation is co� c1.I ogree ro[omply wiih o�l County
adinanc and 5! a gula�ing Plumbing,and hereby �
a�rhori epras f this County io enier upon the
ob t�on ,p fcr inspection p rpos . �
Z SEE REVERSE FOR EXPLANATORY LANGUAGE
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