HomeMy WebLinkAbout1564A ' WORKERS'COMPENSA710N OECIARATION APPLICATION FOR PLUMBING PERMIT
I he�eby aAfirm�hat I hove a cerrificpte oi conxn�ro self ly1667A 338/B .
�nswe,or a certikcaie oi Wo•ken'Compe�sn+�o�Ins�rv�ce, �Bn IREv.taiei�
. a a certified mpy fhe�eof(Set.3800,lab.C.) COUNTY OF LOS ANGELES BUILOING AND'SAFETY
a�l'r�6�71���i7 Company �-TPRL7T�C�m[� �
Cer�ified copy Is hercby fum�ihad. 8�����ul Pdrt� �e �[1i�8
� Cenified co �p p�K�t TO Fllt IN IMtIM ON TYOE) A� _
py is i�led wirh the tounry buildirg inipac-
��o�CIEpO��menl. NUM9ER fIXtURE OR ITEM � FEF ����T
2/6/84 � by:� - �y WATEP CiL)SET '�-�d �
DotO Appli4ont yFq1tF5T
CERTIFICAIE OF EXEMPTION fROM WORKERS' BATH TUB C�S •
COMPENSATION INSURANCE g�R � ,� ���'p�], Of SO. C2�.J1.
(Thls sMlon na�d net bs eompl�t�d tF M�work lnvolrsd br
fha Permlt l�fo.ons h�mdr�d dollan tS100)or ters.� uvwian �qpp��,5/{(��
I cenify thai�n�he perfamance oi�he worA tor whicT rhis � �
permit is issued,I ehall not empioy any perspn in arry mqhner SINK � CIiY TEt.Np.
�o ue�a become subjec�b rhe Workers'CompemWion lpws. ���� � �
ccxmtacroa R.C. . Pl
Date� �ppliwnl - - - - ... GtOit�S wAy�EP /� —
� �I� TO APPLICANT: If, after moking Ihi�CettifiepTe ot �
inp�ion, yo� ahould become subject ro fhe wOrkers' S��������
�ompensa�lon por�sions of rhe labor Code,yov rtn��fonh- ��i� • • ����� 371-5�00
w�th com i w�m such o��swns w �h�s uNM SPRINKIER S1'SiEM
P1' °' °"m,� `"°�� � _ �'�No. 336428 �ss C-36
deomed reroked. ww�a�aha
LICENSED CONTftqCTORS dECIARAi1QN q5iR�7 NO. BY '
�hereby atfi.m dw��am lic��ned unde�a�or�sioM aEClnprx o cas srsrFM �s ounEn � '0
(�pmmencing wi�h$ectron 70p01 oi Oir�sion 3 of(ha Q�siness OUILETS pVEp ��9 r
ard Proiessior�s Code,and my ficenx is in f�ll tarceand�eifeU. 5 PER SYSTFM j FINAL � .
o: VALIDATION O
Licensa Numbar 3��7�12� l;c.Cluu —�_ DArE t+
tL .
FINqL Q
co�r.acro�R(:R Pl�m}sing nr�,.,�e�'f�84 BY �j :
W
� �
1 om s<empl u�der Sec. N
8.8P.C.fa+his reason � , x
P�pn chesk fee
���� RUMBING VERMIT ISSUING FEE S D •s� �
Signnhlro ., � C;i:�:1� .
To,�� 9 od
Plun chpck appLmn+ " i: • • • • •j
S�IVCaIE FAMIIY ' 1 •.''"C.U ll
HOME OWNER-BUIlOER DECIARATION +�om� RC.R. PL[AHB
N4eby of4'vm rhn�1 am eaempr f.om the Contrauo:s liSense � - .-
fo��he fol!owing reoson(Sec�son 7031.5, Bus�ness and Add"ess�'27$5 li.a Ave.
:�i,�
v,otes:�o�+s code): c�+y re�.t�o. 71-5000 ��� ::-Z�i
❑ I,as owne�of rhe propeny,will do fhe work and+he � . .
s+ruch�re is no�intended or a(fered fw wle(Sep�on
7044,Buziness ond Professio�+s Coda). '
CONSIRUCIION IfNDING AGENCY
I herehy aff�.m rha�rhe.e�s a con�nu�i�on Iending ogency fo�
ihe perfwmance of fhe wo�4 for whic�+this pe.mlt�s Isfued
(5ec.3097,Civ.C.).
Lendm's Nome Sec�sity Pacific B�nlc
lender i Address����t ��� �
I ceNily thol I hore reod this oppliw��on and awte thal�he ,
above informolion is cmrect.I agrea to comply with ull Cpuniy
ordinonces ard Sto�e lows regu�a��ng Plumb%ng,ond h�reby ' �
authqize represeMaiives of Ihis Co�nty io enter upon Ihe
abOre-mentioned properly for�nspecr�on purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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