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HomeMy WebLinkAbout1589A (20) WORKERS'COMPENSATION DECIARATION APPLICATIDN FOR PLUMBING PERMIT 1 hereby off�rm thol I have a ceriificole of cor+seni�o self 20�0076 DPW 6/87 � insure,or aca���fico�e oi Workeri Compe�saiion Insuran�e, 7fiA667A o�o ce«+fied copy�hereof(Sec.3800,Lob.C.1 COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS P�ol'�cy No. mpony . Cer�iF� d by furnlah�l. Q/6`✓+� O ��3 iIy% FOR APGLI�ANT TO FI��IN(PR!NT OR TVPE� auitcu.� _ Certitied copy is filed wilh Ihe cou y building inspec- ADDRE55 � Q iion dQpo��ment. � ,/ NUMBE4 FI%TURE OR ITEM � F'eE � Da�e���(y` � LOCAUTV 'L. a�+• � V JApplicont C � WATER�LOSET NFARE57 CERTIFICATE OF EXEM7TION FROM ORKERS' BATH TUB ato55 ST. p_nJ S Y!^��f� COMPENSATION INSURANCE SHOwER OwNER La ,Q r L �J (T�h�Mlon n��d naf 6�eomplN�d N fh�work Inwlwd 6y ' Ih�p�rmH Is lar on�hvndr�d dollan(SI00)er I���.) IAVATORY �DRESS . l �is,.i v 'E% I ceriify tho�in�hs perfo.monce of�he work for which�h�s /� /� �+ o ^7_ pprmil is ifsued,I sholl nol employ ony penon in any monner SINK ��TY /,/r[% /�l�iC.. �E�'�' � 'p�/ tio oe�o bxon+e wbjx+�o+he wwken'Compento�iOn lows. D�SHWASNER CONTRACTOR • � ��.�� L' Da�e Appliconl� CLOTNESwASHER AWREss NOTICE TO APPLICANT: li, af�er mokinq rhis Csrrifica�e of Sw!Mn��NG POOL RFCEPTOR D^2 �r«^� E■smp�lon, you cl+o�ld become eubjxt �o +he Warke.i � Compe�eo+�o�rynviaiqny 4f the IpM�Corls,you must forth- :AWN,•iPR�NK:iR5Y5'E�V, Clrv ���'C 4�vc, TE�.�.s�l-9as" wifh comply wirh wch provisioni or �h�f permil sholl be STo.TE l�C. deemed revoked. wqiEp NEnteR utENSE Np. � (j CV,55 � '36 LICENSED COMTRACTORS DECLARATION D�STR�R NO. SSED Bv I hero6y vffirm thot I am licensed undx provisions ot Chap�er 9 �+AS SvSTEM WTLETS O . (commencing wiih Sec�ion 7000)o(Diuision 3 of rhe Bus�neac OUTlE730vER ond Rofessions Cale,and my Ilcense is in full for�s and effxt. 5 PER Sv57EM F�NA� � i DATE �� �AIIDATION a license Number �� LIc.Clasa � � ' U �i FINAL � Conhoc�orr�C 1Q ` Date BY O . ❑ I am exemp���de�Sx. -3��� U : w B.BP.C.For�his reason plan check fee , N � Da�e� Z PLUMBING PERMIT ISSUING FEE S tJ � Siqnature TOTA�FEE � � Plon check opplican� SINGLE FA.MIIY HOME OWNER�BUILDER DECLARATION Name �� ��'��i1 I hereby oHirm�!�at I am exr.mpi irom ihe Contractcr's ticense Add•ess �. . Law for the lol�owing reason(Section 7031.5,Business and � � � •' �ofess�oM Code): Ciry Tel.No. � � � � G j� ❑ I,m owner of�he proparty,will do the wak and�he � 6h�tlurc is nof'mended ar oHarad fcr wle�Seclion ► s.� r� � ��j,.• . 7W�,Businms a�Profassions Code). ���' � Y�" . CONSTRUCT!ON LENDING AGENCY I hereby�firm that�here is a cens�ruction lending agenty for rhe performance of ihe wor4 for which�his permii is issued (Sec.3097,Civ.C.). lender's Ncme Lender's Address I cenily Ihol I heve reod th�s opp�icotion ond s�o�e�tio1 Ihe , above informaiicn is ccrracl.I og�x la comply wi•h a!I County ord�nances and S�a1e lows requloring Plumbing,end hereby au+hori e rep s +et�ves of this Counry�o enier upen the obo� ent� a properly icrirspeciion purpcses. `� SEE REVERSE FOR EXPLANATORY LANGUAGE "v�f/ l� S �igno i ermil•ee Da�e . ., r-r"' l ' ('� !! �� _ %'l t`,'� . .[7 -i��1^ rr � �� � �y. ':�: .j. I !l (�1, � G, ., /, :) C) T t.! :� i:. , =�' .1�; �: �_'� i i; % ti: ' , i� � . ! . s� ti ! , ��`, `'" �, � i._ r . � �, .� ��.'� _ � -��; i� i � � � � '� � . � - � ��_ ,, -, ��, ��_ -, I 7 ' ' f •1 ,, � i (/� � 14 �� � � ' � C, � ' � � j � � �� 7�' �: N � n' 'a V� . • ' � �. 1 E . � t ' . 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