HomeMy WebLinkAbout1530A (8) r ,
WORKERS-��PE�,s�N�«ARAf�o,� �� APPLICr�►Ti�RI �Q�R PLUjViBti��PE�iri�i�,���� � � �
I hereby offirm that i have o ter�ificote of consent lo ut! 20-D026�PW 6l87 ; � - ;' .^' : �
insure,or o cerlificate ot Wo�kars'Compenwtion Insuronce, 76A667A � �`- �'�
or a ceriified co�pys th1ereof�$ec.3800,l C. r /� . COUNTY OF LOS ANGELES DEPT.OF.PUBLIC WORKS
PQolity No�d����"" "Compony ��'���� �
Cerlified copy is hereby furnished. BUILDiNG
FOK APPLICANT TO FILL W(P{tINT OR TYPE) ADDRE55 2 i d z3 J�i U✓�
Cerlified copy is filed with 1Me mv ry building ins �
iond�epsa�r�m,enf. r$1MBER fl%TUREORITEM � fEE ���rcY
Do1C�Sl�Appli nt WATERQOSEl NEAREST
CERTIfICATE OF E MP 9N FROM WORKERS" � BATM TUB CROSS ST.
COMPE N INSURANCE . SHOWER OWNER d�)���?
(Thi�wction nr�d not eompbbd.H ffi�wArk inrolrad 6y Mpi�
Ih�p�r�wN Fs for oh�lwndred aellari(31DOf or I��a.) �_ LqVqTORY A��RE55 �
I cerfify Ihnl in the performonce of ihe wark far which this ��Ty TEt.NO. �
psrmil is issued,f sho11 nof employ any parson in any monner SINK
so aa lo become subject fo rhe Worker' ompansotion La . � DISNWASHER COMRACTOR (/
[7S `-'Py1 1
DoSe�APPlic QO�NESWASHFR ADDIiE55 �b �
NOTICE TO APPIICpNT: ! af r making this er�ificate of �
E■amption, you ahoul b ome su6'�ect to the Workers' � SWiMNJNGP00�RKEPiOR ��Ty . '^� TEL N0. ��f� �t
COmpensalion provisio the Labor Coda,you muif forth- UWNSPRINKLERSYSTEM i
with compty wilh suc provisions or thia permit shall be STAT � �C� UC. 6
de�med revokEd. � ' WA7FR HEATER uCENSE NO. A C1A55 �
tICENSED CONTRACTORS QECIARATiQN OISTRiCT NO. ESSED BY �
I hereby offirm thpf 1 am liCanaed under provieions of Chapter 9 GAS 5YSSEM OUFlETS ��_ �
(commencing with S�ction 7000)of Ofrivon 3 of!he B�ainas - OUTLEf50VER } '
and Profeuions Code,and my license'rs in full force and effect. � 5 PE 5YS1EM FINAI YAl10ATION LL' �
oY`,� onre � �
License Number lic,Clas�
FlNAL �
Controctor � �'��� �ate �9 Z' � BY O `s
Q ti1
'� 4 om exempt under Sec. a ?
t
8.8P.C.for�his reoson p{an cheGk fee
oa�a: �t 5 3 Q A � °
PLUM8ING PERMiT ISSUING FEE 5 #� �. • �S '
SigtwWre r �( �� �
TOTAL FEE (�� �
Plan check applicant . i
SINGIE FAMILV `I+t 4 6 5 p !
HOME OWNFR-BUIL6ER DECLARATION �ms y�!��r,Q x i
I hercby offirm that l am ezemp�from�he CoNroctor's Litense � "
Law for the following reoson(Section 7037.5, Business ond Address ��t ��$9 `
Professians Code): �iry Tel.No.
❑ I,as owner oi the properry,will do ihe work ond�he 4
� 1
str�dure ia not intendad or offered for sale �SeUion i
7044,Business and Professions Codej. I
CONSTRUCTION 4ENDING AGENCY �
I herehy affirm tbat there ie a mnstruction lending agency for �
the performance of the work for which this permit is issued
(Sec 3097,Civ.C.). (
Lender's hlame I
Lender a Address �
1 cerlify that 1 hove read lhis appl�cafion and state fhol�he �
obove informa�ion ia corrett.I agree�o tomply with all County
ordinances and Sta�e fows regufoting Vlumbing,ond he�eby
ou�honze repre�enlotives of ihis County to eNer upon the � � +
a6ov eMiOned p�opBrty for inspeCtion purposes.
� r2 SEE REVERSE fOR EXPIANATORY LANGUAGE I
Signature of Permi ee Dote �1
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