HomeMy WebLinkAbout0811A (4) WORKERS'COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT � �
I hereby affirm �hot 1 have a cemficare of comen��o self �bq6y�q
insure,w a ce.rif�mfe oS Wwkan'Compe�sa��on Insurance. CE Bi7(RFv.loie�)
or o ce�+�f�ad wpy�hereof($ec.3800 b.C.) COUNYY Of L05 ANGELES BUILDING AND SAFETY '
❑cy Na�'N�mpo�y � �
�rfied copy is hereby furnished. e��� �_^ �/��
i{ied copy is filed with�he eouNy buil�inp inapec- �R APGLKAM TO flLL IN IPRINI Oli TYPE) A�� J �
��o�depOMment. NUMBER FixTUREORI7FM � F� LOUIUfY
�p10 _/S �pL�on� WATE(t C1�LLSET �St '
CER�IFICAiE OF EXEMPlION FR WORKERS BAiH 7UB �f053 ST. �
COMPENSATION INSURAN� pyy�p ,G
SNOWER
(This s�ctlon nomd not bs eomp�aNd I}fh�work Involvod bY �u
fhe p�rmif 1�}or on�h�ndrod dellan{3100)er t�».) lAvatoRv
1 tertliy�ha�in�ha perfortncnce at the work for which rhis �
permir�s ias�ed.�sholl�ot emploY eny pe�son in omp mqnner SINK Gn � f
so m ro beeome��b�eN ro rhe Worken'Compen�arion lovrs. �w�R �A ;
Dpfe epplicon� QOTHES wASHER �� / :
NOTI�i0 APPUCANT: If,aher mak�ng�h�a Ceaff�mfe ot SwuamiNG POa RECEVTOa �
Exampuon, you ahovld beeoms s�bjeer ro �he Waken' � �
dtr TEI.
Compemation provision�of rhe bbor Cpda,you mvi�forth- AwN SPRMyER SrSTEM
wAn comply witli such prorision7 or lhis permi�shdll ba SfA7E � LIC. /�dL
deamed�eroked. Wq�Ep NEp,1Ei! � ��rd0� '�" MSS `�•J .
U�NSE.p CAMIjpCTORS pECIARAiION dSrR�c7 wp. SSEp BY �
I hereby affirm Mw�I am licenseQ urderprprisiam otf�ioptx 9 �56r51FM OUr1FfS \O
(commencing with$edion 700Q1 Of UirisiqD 3 of�ha&ninns qlitk75 pyER ..
a�Professions CodO.and my liten]e is m f�ll fqrt�and effecf. 5 PER SYSiFM .fIIVAI - Y �
vAunanoN d
Q�� Sc.�'�- ontE-�i.,l,�✓,� � ;
Liten�a Number��_.lic.Class�
FINl4�! �
Controcror Date � � F•
W
❑ I om exemp�under Sec. , d �
N '
a.av.c.to�rh�s.acaoo plon check fee � 2 :
��8� FIUMBING PERMIi ISSUING fff f 'Q
Sigrrotura �
TOTAL ffE T�.tl
:-`C�I.� !i
P:on check app��can1 �
SINGLE FAMRY • •
NOMF OWNfR-BUIIDER DECtARATION Name r�.� � � "
I hereby aff�rm that I am eaempt from ihe Connauor's Liceme ��� � � �y��;n
Law for the followira reazon(Sec�ion 7031.5,Buainess and "
Professions Code): Ci�y 7e1.No. - �
❑ . e •;;^:'Uii ,
I,as owner of t6e propery,wrll do�he work and the
a�.ucrure is no�imended or offer�io.wla(Sec�ion ► !��.� �-�J �
7044,B�niness ond P.otess�ons Code)�
CANS�RUCiION IENDING AGENCY '
I hereby aff��m tha�there i�o construcrion lend�rg agency for
the parformance af the work for which fhis permi�is issued '
(Sec.3097,Civ.C.).
Lender's Name '
Lender's Address �
I ceniiy tho�I hove reod this oppiica�ion and sWro tba�the , .
abore lnformaTion is correct.I ogree b comply with all Couny �
ordinances ond S�ale lows regu�a�ing Pl�mbing,�ond hereby
aulhori:e represento�ives o(�his Coun�y to en�er vpon �he ,
abora�me�tioned pr perty for im �ion purposes.
SEE REVERSE POR EXPLANATORY LANGUAGE
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