HomeMy WebLinkAbout1594A � WORKERS'COMPENSATION DECLARASIOP7
j hareby affirm lhat I hove o certifkate ot Eo�;���fo 5a�f �,A AWPtfCAT10N �OR P4UNiBtiVG PERMIT
nsura,or o cerfliicole oiWorkers'Compen:ation Insurance, �gn(REY.ipi8i)
x a certified[epyr iheretli(Sec 3800,Eo .C.�„ COUNTY Q��LOS ANGECES BUILDING AND SAfETY
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b4icy Na. .. G� Compony i� . 6f�f0
jCertified copy is here6y fumtshed.
� FOR AGPLICANT TO Fitt tN(Pf7iNT OR TYPE� BUIL�ING ,r
Certified copy'r5 filed with fhe counry building inspec- ADDRES4 y g� �,
li6n department NUMBER FIXTURE OR ITEM (� FEE �"n,
�ate ���r APP�'4o^� � WATER CIOSEi .. �^ NEAftEST l.� ",r
� �RiIFICATE OF EXEMPiION FROM WOR �. BaTH TUe G� �J — CROSS 5T. 7
COMPENSATVON INSURANCE
�(thl�sec�ion wead no:bv complarad�f tho work Involr«!6y.. SNow€R fp- .�- ��a � .
�iYro parmit is�4or onr hundrod doUan(Sf00}or I�u.) uVATOav MAIL ` ; �+�,.
'1 certify that in the performance of the work for which ihis ADDRESS ! �4Gf
�{. �permit,s issued,I shaN not employ any person in ony manner S�NK 6' Ci7V TEL.NO.
,so as to become subject to the Workers Compensation Law�. DISHwASHEA p,
. . _ . CONTRAC?OR� f f .
Dofe dpplicanf CLQTHES WASHER
A�ORESS �
-'NOTICE TO APVIICANT:�If, afMr moking ihis Cerlifimte of � � ^ ..'�J /� I
�EMemplipn, you shoufd become subject to Ihe Workers' SWIMMING VOOL RECEPfOR �
��• __ ___ _ .. . ._
� ♦Compensation prorisions of tha Labor COd¢,ytlu rrtvEt fortfi- �pWN SVRINKLER SY57EM � � CITV hi.Np.��4�� .. . �
witN comply w��h such provislans ar �hi}penrti�S�W6 I�. . . .. ,_ . .. .. . .... STATE.� . . - UC. �
G�eemedrevoked.� � . � WAiERHEA7ER �,� ,r IICENSENO. ��7G�1�' CLASS �'��
LICENSED CONTRACTORS�ECLARATIQN DiSTRiCENO. _,...PR_, BY--,- - -�-.- - � :
1 hereby offirm ihof!am licenud�nder prorisians of CJwpfer 9 -. GAS SYSTfn1-.--:-..,jlllFt�iS-�� �.�. -. -.' �. -. .-. . '"' �� ,"- - � f
(rommencing wirh Section 7000)of Divis�an 3 of the Businew IXf1LET504ER � � F
and Prafessions Code,and my Iicen4e is in fu(I fpce and eHett. S VER SYSTEM - FINAL -�
' ,�_- - - VAk1DATlON__ - -- Q
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�---- - - y�. _ - -- o.are,i'.tp=�� u
- ikanw-IYumber����i.�� . Lic.Ciass� . . . - . . � �
rf (� . . � . FtNAL Q
Comwctor�QL�G��Dme�'L2� . 6Y �"
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I am ezempf u er Se. pw,
M
O.BP.C.for this reason - `^ "
Plan check fee
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:
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PtUMBING PERMif ISSUING FEE$ `0•s6 ;' .' il ` ' • �' '
Sign • �
....----. .IQTAIFEE.._....__.,_ ._ �j. - � .---------'---...__.._._...---�------ -_ -------._�_. ._ _
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Plan check applimnf • * f�� �
SINGLE FAMILY . `-
HOIvVE OWNER-BUILDER DECLARATION Nome _
I herehy affirm tho�V om exemp�trom ihe Contractor's license � � �
tow for the follawing reosan(SeUion 7031.5,Business o�d Address
� trofeuions Code): City Tel.No. �
❑ I,as owner of the proper�y,will do the work ond the
srtuc�ure Is nof inrended or oNered for:ole(Secfion �
704d,Bosiness and Professions Code�. � � �
� CONSTRUCTION IENDING AGENCY
I hereby affirm fhot rhere is o construction lending agency for
! the peAormance of the work for which ihis permit is issued
� (Sec.3047,Civ.Gj.
�
' Lender's Name � �
� Lender_'s Address �
Vi certify lhat I have read this app4icotion and stote Iho��he � �
obove information is co�rect.I agree b comply with all County '
ord�nances and Sta�e laws regulating Plumbing,ond hereby f
ouihwize represematives of�fiis County to enter upon ihe 1
obove-menfi ned pr per or mspection purposes. !
SEE REVEQSE FOR EXPLANATORY LANGUAGE 1
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