HomeMy WebLinkAbout1594A (9) � WORKERS'COMPENSATION DECLARASIOPi
j hareby affirm lhat I hove o certifkate ot Eo�;���,0 Sa�F �,A AWPtfCAT10N �OR P4UNiBtiVG PERMIT
nsura,or o cerfliimle oiWorkers'Compen:ation Insarance, �gn(REY.iDlei)
x a certified[epyr iheretli(Sec 3800,Eo .C.�„ COUNTYQ��LOSANGECES BUILDING ANDSAfETY
l / p
b4icy Na. .. G� Compuny i� . 6l�f0
� Certified copy is here6y fumished.
� FOR AGPLICANT TO Fitt tIJ(PkIM OR TYPE� 6UIL�ING ,r
Certified copy'r5 filed with fhe counry building inspec- ADDRESS y �� �
lion deporiment NUMBER FIXTURE OR ITEM (� FEE ��"n,
Oate ���� APP�'40n1 � WATER CIOSET .. �^ NEAftEST l.� ",r
� �RiIFICATE OF EXEMPiION FROM WOR �. BaTH TUB G� �J — CROSS 5T. 7
COMPENSATVON INSURANCE
�(thl�sec�ion weed no:bv complarad!f tho work Involr«!6y.. SNow€R fp- .�- ��R � .
��Fw pormit is�4or onr hundrod doUon(Sf00}or I�u.j uVATOav ��� ! ;�,�' "
'1 certify that in the performance of the wnrk for wbich ihis ADDRESS
+{. �permit,s issoed,I shaN not employ ony person in ony manner S�NK 6' Clri TEL.NO.
,so as to become subject to the Worke�s Compensation Law�. DISHwASHEA p,
. . _ . CONTRACTpR� f � .
Dofe 6pplicanf CLOTHES WASHER /
A�DRESS �
-'NOTICE TO APVIICANTc If, aSMr moking ihis Certificote of V � ^ ..'�J /I �
�EMemplipn, you shoufd become subject to Ihe Workers' SWIMMING VWL RECEPfOR �j O�.,�y �
�' ♦Co nsation orisions of the La6or Code, -- �-- - .. . C
� P� Y��vSt fortF�- iAWN SVR�NKIER SYStEM ..- CI7V TEI.ND. 7 J fi-O�."Y .. . 1�
witN comply w��h such provislana u this penrtit 9F1o6�. . . .. ,_ . .. .. . .... $TATE� � /� - UC. A �
G�eemed revoked.� � . � WATERHEA7ER �,� ......� ,r UCENSENO. ��7{(�1�� CLASS L"��
LICENSED CONTRACTORS DECLARATIQN DiSTRiCENO. _,...PR_ BY--,� - -�-.- - :
1 hereby offirm ihof!am licenud onder provisians of CJnpfer 9 -. GAS SYSTfht-..--:--.,jlUF�FiS-�- �_-�. -. -.' �. -. .. . ." . ,"- - � f
(rommencing wirh Section 7000)of Divis�an 3 of the Businew IXJTLETSO4ER � � F
und Prafessions Code,and my Iicen4e is in fufl fpceand eHetf. S VER SYSLEM - � FINAL
• �_ _ VAElDA7lON -- - --Q
-
�---- - - y�. _ _—-- --. o.are,�:-.�1j=d� u t
- ikanse-IYumber ���i.�� . tic.Ciass � _ . . � �
f� . . �. � FtNAL Q
Comractor�Q��G��Dme�12��� . 6Y �"
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I am ezempf u er Se. pw,
M
B.BP.C.for this reason - `^ "
Plan check fee
�, a ,.4r, = s
:
; , -
_Y PtUMBING PERMif ISSUING FEE$ `0.�"6 ;: ' il ` ' • �' �
Sign
.. .. --.. .......----. .IQTAIFEE.._....__.,_ ... " _ .---------'---...__.._._...---�------ -_ --------._�_. ._ _
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.. _ ._ .... ......._.__....—�-�--
..------.......__.............___._ .. . . _ � i � � ... [
Plan check applimn� � a F�� ; - -
SINGLE fAMILY . `-
HOIvVE OWNER-BUILDER DECLARATION Nome _
I herehy pftirm thol i om exempl trom ihe Contractor's license � i �
taw for the follawing reoson(SgUion 7031.5,Business o�d Address
� trofeuibn5 Code): City Tel.No. �
❑ I,as owner of the proper�y,will do the work ond the
p siruUure Is nof inrended or oHered for:ole(Secfion . �
� 704d,B�siness and Professions Code�.
� CONSTRUCTION IENDING AGENCY
I hereby affirm Fhat rhere is a construction lending agency for
� the peAormance of the work for which ihis permit is issued
� (Sec.3047,Civ.C.j.
�
' Lender's Name � �
� Lender_'s Address �
Vi certify that I hove read this app4icotion and s�ote Iho�5he � �
obove information is co�rect.I agree b comply with all County '
ord�nances and S�a�e laws regulating Plumbing,and hereby f
auihwize represematives of�fiis County to enter upon ihe 1
obove-menfi ned pr per or mspection purposes. !
SEE REVEQSE FOR EXPLANATORY LANGUAGE +
�3-a d.f i
SignafUre o Pe mitlee pple
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