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
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