HomeMy WebLinkAbout1591A WORKERS'COMPENSA7�ON DKLARATION APPLICATION FOR PLUMBING PERMIT � '
1 hereby affirm�hot 1 hore a cer��Kcote af consanl to self ly4eyq
cnsure,o�a ce�hf�ca�e of Wwkera'Compenw�con Insurance, CF ev(RFv.�oiei i �
or a cen�f�ed copr�he.eof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. � Cpmpony '
� Csrt�fced copy�s hereby furnishad. .
OfOR APPLI�AM TO F�l W(iRIHT OR T'OE) B��S �3�p�0 t� Y
Ceniiied copy�s fil�wi�h�coun�y b�Hd+rg�mpec-
t�on depanmen+. NUM9Ex POIfURe oR rtEM � iEE
io�w*Y ,aN�o�rd C.�e. / 6s"
Dote�_T_AppliGont WATER LWSEF fJEARE57 '
CE1[fIFICATE OF E7(FMPTION FROM WORKERS' Bnfn iVB �ST� '�w e.�k �.� �
CAMPENSATiON INSURANCE S��p owwEp ��,p�� �'.. �' .
(Thl�sMlon navd nof 6s eemptofad if Tha nark inrotr�d by �
tha permlt Is foe on�hundrod dollan(SI00)er tass.) �yqppRy �'�� � Fi, S
ADDRE55
I cenily thai in�he performonm of�he work for which rhis �
permit ia issued.I�hall no�emplor 4^Y Pe�son in any manner SINK C�Tv � a� iE�;.Np.�I���3 .
ao m�o become sub�ac��o�he 1No�ken'Compe�natiqn lowa. -0��w�p � �
/� CONTRAROR
Oote e^�ieanl !��`�� CIATHES WASMEa �
NOTICE TO APR1GqNT: li, efter 'king�his Ge�M�mte o A�R�
Exemp�ion, yov �houtd becom a�b�en �o �he iMorkers ��������'�
(.ompenwiion prorisiorn oi�he Labor Cade.Yo�muy fonh- Giv 1F1.Np. ,
with r�mply wnh suc� po�is:pns or !his pOrmit ihpl', be ���INKIER SVSIEM STATE LK. �
deemed re�oked. yyqhR�pf¢p ��J .� ��I10Erv5E NO. CiA55
IICENSED CONTRACiORS�ECLARA�IQN rn57RKi ev0. D ev
I hpreby aHirm tFqt 1 om IitM1SBd undC�p�OviSiO�y 4f(nOP�C�9 �SVSf6M ' q,17ki$ /� -`.t/.��
ko�nmencirp w+�h Senion 70pp)of D�rision 3 0�Ihe 8us�ness OUlltTS pVER �'
o.
ard Professiom Code,ord my licer�e is in 1�11 fwce mdeffecf. 5�Ep 5+51F�N FINAI ' i VALIDATION O
DATE ��' �C V
lir.prrse Number Lic Claa c' p� '
FlNAL,.. . � � •
i
Ganfrotlor- , . Date - ' BY '....1�I..i�'-� V
� W
I pm exempt�nder Sec. N '
B.BP.C.for thiy reason Plan check fee
Dara:
PLUMBIIVG VERMIT IS$UING fEE S f, ��J : � �r.I r;
Sigrw�ure , `- .
TOTAI FEE rr.y�"� . e � s a .
•j
vi��h�a�iK�.,� I • ::C�['
�INGIE PAMILV '
MOME OWNER-BU1l,OER pECIARATIOIV Name _ '
I hernby aflirtn thol I am exempl 6am Ihe Conhacfor'a liceMe ' v •:�i�-�.';:
lpw For the fulbw�ng raason(Secfion Np1.5.Business ond �� ^ .
Aofessione Code)' C;ry TeI.Na.
G�:iL•-f:�-
� I.as ow�r oi�he p.operty,will da fhe worG and ehe ,
snucwre is no�infended a oFfered far wle(Sectivn —
7Wa.B�a�ne�s ond Profess�ons Code). .
CONS�RUCi�OM IENDING AGENCY
I AarebY offirm tlql lhna is a construction lending agancy}a
�he per(wmance of�he work fw which rhi�pe.m�t is iuued
LSec.3097,Civ.C.).
Lende�'s Nome
Lender's Address
I cen�fy tlw+I hove reod rh�s applico��on ard sraie thu��he �
above�nfama�on is conect.I ogree�o comply wiih all CouMy
mdimnces and S�a�e lows regulot�ng Pl�mb��g,o�d hareby !
ou�ho��:e repmema�ives o! �his Couny b eNer upon the .
a6ore-men�ioned properfy frn inspecnon pu.poses.
�,���,, � SEE REVERSE FOR EXPLANATORY 4qNGUAGE
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