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HomeMy WebLinkAbout1589A (22) WORKERS'COM�ENSATIONDECIARATION APPLICATION FOR PLUMBING PERMIT 1 hereby offirm �hot I Fave a ceriilicole o(consenl 10 seli 20�0076 DPW 6l87 C� ins�re,or acert�ficafe of Workari Compe�xotion Insuronce, 76A887A 1 I or o cer��lied copy�hereof(Sec.3800,Lob.C.1 COUNTY OF lOS ANGELES DEPT.OF PUBLIC WORKS �'� P❑olicy No. mpany Certifi d c by furnisK9�1. �/NU� ❑ ��3�Iy�� FOR APPIICANT TO Flll IN�71tiNT OR TYGE) BUILCING � Cerlified copy ia filed wilh Ihe cou y building��spec- '��� � � fiondqpor�meM. / NUMBER FI%?UREORITEM @� FEE �p�ALITY � r WATER CLOSET 'C a�• Do�s"�Apul i4ont �,I I�EAREST CERTIFICATE OF EXEMPTIQN FROM ORKERS' BaTH TUB CROSS ST. �7,n/ � rl N S� COMPENSATION INSURANCE SHOwE4 OWwER � ,�2./ L _Q (Thli t�tllon n��d nm 6�compl�t�d 14 th�woAc Irnelr�d b� �,� fh�p�rmll h}or on�hundnd dollan(SI00)or I���.) tqvntOnv aUDRESS . � `��✓ � �E( I cerY(y tha�in�he pe.fwmance of�he work for wh�cti th�a � permit Is hsued,I�hnll nof employ any penon in ony manner SINK CITY � �� �C��' iEt.h10. b •-fj'3� fo at to 6ecome�ubiecl to�he Worken'COmDs�fO�iO�LOwS. DISHWASNFR coNrancroa • � ��.���'. pplp qpplicont� CLOTHES WASNER AD�RE55 - NOlICE TO APPLICqNT: I(, offer making rhic Cer��fico�e of SyrIMMVNGPpp�RECE7TOR '�^2 , ��rr�N Eaempfion, you �f+ould become �ubjecr to the Workeri' CiTY TEL.NO. Compinso�ion prorifiona of the Labor Code,you must forth- �eyyNSPR�NN!FRSYS?EM S�°"J✓��� 4LU�, $����7x with eomply wi�h �uch provi�ion� or �h�� permit �holt be �� STATE uC. / deemed revoked. w,orea He�ha ���'+��� � G �� � �3b LICENSEO CONTRACTORS DECLARATION OiSiR�CE NO. SSED BY I hereby afflrm�ia�I om iicanted urder provi�ions of Chapier 9 GAS SYSTEM WTtETS O (wmmencinp w�rh Sec�ion 700p)of Div��ton 3 of rhs Bus7nma CWiiETSOVEa ond P�ole�s�on�Code,ond my I�cenx i�In full fwce and effect. s vEk SrSTEM FINAL VALIDATION d � DATE �� � p licsn�e Number���lit•Closs CJ FINAL � Convoaor � ` Do�e �Q BY O � I am e.emp�under Set. �3� �+� W ' 8.6P.C.for this reoson p�an chack fea , 0. � Oob: ? PtUMBING PERMIT ISSUING FEE f (J Signo�ure TOTAI FEE � �� Plan chxk applicant S�NGIE FqMILY - HOMEOWNER�BUIIDERDECLARATION Nome '�� "��'" I hereby offi•m ihar I om eyemot from the Con�.oc�or i License qddress er • • • • Low for�he fcllowing reason�Section 7071.5, B�siness and " Mofeys�om Code�: �;iy Tel.No. 1 • ° � �.J L ❑ I,as owne�of itie p�operiy,will do rhe wak and rhe _ � shucture is not in!ended or oHered for wle (Section ► u;!;.1�."�'r.7.` ' 7044,Businns and Professions Code). � :ONSTRUCTICN LENDING AGENCY I hereby nifirm�ho�rhere�a o tonsvuctton lendinq ager.cy for rhe performance of ehe work fe�wh�ch�tiis permii is issuad (Sec.3097,Civ.C.). Lender's Name lendei s Add�ese I cer�ify�hoi I hove recd Itiis app�ico��on ond slate Ihot ihe ► obo�e intormarion�s co�recL I agre�ro comoly w��h oll Caun�y o�dinances ond 5'a'r Iews reguloting Plumb�r.g,and F.ereby author]i e reu �ctives of th�s Coon�y io e^�•ar opon�he obov.6�F+e�i' e property fcr inspection pu�FCses. � SEE REVERSE FOR EXPLANATORY LANGUAGE . '�// C� (C �gno• r e�m�iree Do�e c. _ �''� • _ �' �;;� '� :',:';� '1: - 'i� ^ , ;; "- '.;: �.•c' � � .. ;, � r 5 J :. 16 �., •.� :i .• 1 ; � �J vl J. j• ' ; i.r• 'i '.' 'ti �,� .. � ; ��: 1 ' ;l� �— _�`� ,'1 � � � ` � .'' t � i ' - 1 _ I •, ' , '.�l' � '�7 7 ~ �— 'N i+ ' � �r! �� r (�/� �. ' � I �i-', �.J / ' � 1^ I �r 7•? N � ' j 7- �� � 'c u� ' � . , . I � 1 . � � ' ; i �i � ' �� 1 �i :.� : i ' � �. � � ' �' � � i �' �, 1 1 �� � . , � � �t, � � � � � 1 � U ; � ; 1 ' �. 1 1 ' 1 `� � j ` . ' I � � 1 ,i � 1 ' '� I � � ; � � 1 , I , ; , 1 � � ` � � i .�� � . 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