HomeMy WebLinkAbout0795A (4) WORKERS'COMPENSATIONDECIARATION APPLICATION FOR PLUMBING PERMIT �
I hereby oiSirm �t�at I have u ceri�f�co�e o(conse�t to sel( �yq�y�q
insure,o�o ceri�fico�e of Workc+s'Compe�sa�ion Inauro�ce, CE 617(RF.V.IO�Bt)
or a certified copy thereof�Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILOING AND SAFETY �
Po�licy No. Compony
Ceriif�ed copy is hereby furn�shed.
aFOIt APqICANT 10 F1LL IN iPRINT OR TYPE) 8U1��� .
Cerlified copy is filed wi�h ti�e couNy 6uildmg inspec- A��� "�f � C
��o�dBpffrtmenl. NUMBFR FIXTURF ON ITEM Q9 FEE �«K�r� �y n
WATfRClOSFT �� �
Da�e AppliSant NEAREST /'� ,
CERTIFICAiE OF E%EMPf10N fROM WORKERS' B.�7H iu8 CR055 Si.
COMPENSATION WSURANCE pwrAR � �
(7hla sMlen nwd naf b�eompl�t�d if th�vrork invotwd by S��p �
� fh�p�rmlt��for oq�h�ndnd dollan(S100y or I�n.l IAYATpRY q�pp��,5p�� � �
I I certi(y iho�in�he periamance oI the work for which Ilris
permir is iasued,I ahnll rm�employ oiryl persbn in ony mannea SINK Ciir�A � � 7EL.NO. ��I- �
so m ro 6e ome subjecl to�b9 Worl�ers'Co penwno�Lows.
DISNWASMER CONTRAC�OR �
Dol � PPlica\ � � � � CIATMES WASFIER �
NOTI O CPLICANT: If, ah mvking hia Cereifica�e of A��
Eeem ivn, you vhovid become su6jea to �he Wo.kers' Sw�MnnuvG vOIX RECFvrOx
CIIY TEl.NO.
(�IPpCrqplion prO��S�Oro of ihe LCbO�COde,ypU musf Sorfh- (pyyN SiRINKIFY SYS7FM
� w!ih tomPil' wirF. suth provEs+ons pr th:s ppfma+hu7i be 57a7E UC.
deemed�evokBd. WAiER MFATFF ����� �
�ICFNSED CONTRACTOR$DECIARAIION DISIRIR NO.
� I h�reby ufi�xm IFqt I om I�ce�RGd urder provisio�.d Chapler 9 CiAS SVSifM WTIFiS ,!'�
(commMcing with Sea�ion 7pp0)oi Di�ision 3 pi ihe Businesa q�T1FT1 pVER v '�" .
ond Profess�om Code,ond my lice�ne�s in full force ond eHec�. S FEN SrStfnn FINAL 0. .
o,o� vn�i oN o ,
Licen�e Number Lia Class f O pC
FINAL Q �
� Conlrucfor Pote BY ~
V
a w
�am e.a„pt„r�d��s��. +�-
N
B.BP.C.for tl+is�eason Plon check fee , ?� �
���� PtUMB�NG VERMIT ISSI}ING PEE E U �
Sfgna�u.e __
' TOTALFEE "� .
via+d,�a�u�a+
SINGLE fAMILY
HOME OWNER$UILDER DECLARATfON Noma � �
I hereby aff�rm thot I om anemp�from rhe Connac�or's ticensa
law fo.+ha fdiow�ry reasvn�Sec�.on 7031.5.Bus�ness ond '�`��- � ,
P.ofessione Code): �'N A � Tel.No. ry � Q �
� =G7 5,, _
I,oa owner of rhe popeny,will do ihe wa4 ond rhe
snucwra rs noi in�ended w offered for sale (SeUion � � • • • . .�
i 7W�.B�s�nees ond P.ofeeato�s Code�.
CONSTRUCi�ON IEND�NG AGENCY � ° =G�n
� I here6y aff�rm tYrot�hve�s o conskuction ler.ding agency for ��r
! rha performance of the wo�k far which this permi�IS iSLUBA � ' '<J U�� •
� (Sec.30D7.G�.C�.
i
12.::Q-aJ '
Lender's Name
Lende�'s A�dress
� I ceri�fy thol I have read ihis apPl�cohon ond s�ore thol the ,
. ,p6w�e i�rfdmo�ion�s careci.I agree�o comply wi�h oll Coumy
ard�nonces ond Sw�e lows reguloting Plumbing,and he.eby
o���+w�ze raprpsenlo�ires of thix Counly lo enter upon Ihe
�- 4�ve�meneioned poperiY jor in4peUion pu� es. .
' SEE REYERSE FGR E7(PLANATORY LANGUAGE
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