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
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