HomeMy WebLinkAbout0990A WORKERS'COMPENSATION DECLARATION p,pp�,��Q,TIOR! FOP P�UNlBlR�G PEEtMfT �/�
I hereby affirm that I have a certificote of consent to self 76A667A �
insure,or n certifimte of Workers'Compensation Insurance, CE 8�7(REV.to/ei)
or a cart�ifsi�ed copy thereaf(Sec 380D,L jb1.�C.�) COUNTY OF LOS ANGElE4 - BUILDfNG AND SAFETY
aty Nd.�� G�o �mpany i a-"-'.' �/k..
Certified copy is hereby furnished.
OFOR A➢PLICANT TO FlLL IN(PRINT OR TYPE) App�� �1-���+ �
Certified copy is filed with the couny building inspec- L a1 �,
tion dBp6rime NUMBER FIXTl1REOR ITEM � FEE ,/ '
�Date��Appli4ant �7 yi! (� �.gq�s `) I
' - WATER CLOSET i
CERTIFlCATE OF EXEMPiION FROM WORKERS' sniH iUB p.� Ck05s 57. ;
� CQMPENSATIOhlINSURANCE ��R OWNER � .�� �
(ihk soction nad not b�complN�d K Ti�s werk i�nolvod b� � ,+ r
th�p�rmk 1�for oua hu�dr�d dollan{5100}or Ina.) tqvarpRv ,Z d� A�pp�RE55 y C '
1 certify ihat in ihe performonce of thB work for which fhis / SINK � (�j7 CiTY TE�,�p, �
permit is issued,I ahall nat employ any person in any monner � e �
so as to become s�bject to�he Warkers'Compensation�aws. / DISNWASHfR /� � '
�v WNTRARpR �a ,� i
c��
- �ote Applimn} � CLOiHES WASHER Mr ' � ;
ADDRESS
. NOT�CE TO APPLICANT: If, after making this Certificate of ��Lr , i
Exemption, yo� sho�ld become subject to the Workers' SWIMMINGPOOIRECEPiOR �
Compensonon provisions of rhe Labor Code,you musr forth- CiFv '� iEL.NO. � �
LAWN SPRINKLER SYStEM
wilh comply with such provisions or this permif shall be STASE )Jy�^� �� �
� deemed revoked. wnhR tiEnrE2 � � ��EM��� -(SY> ci ss j
.. • IIEENSE�CONTRACTORS DECLARATION DISTRICt NQ. PROCESSEp gY ' �
4 hereby offirm Ihof I am licensed urrder provesions of Chapter 4 � GAS SYS7EM OUTiETS (y /Q �t
� (commencing with Section 7000)of Division 3 of the 8usiness OUTlETSOYER �' �
ond Profeuions Code,and y litense is in fufi force and effact 5 PER SYSTEM ' � %
��{ ( DATEL �u�-�7 auoar�on► � :
icense Number t�c.Cfass� �
� �/GTlV� �a 7�+,�/n FINAL �
, OMmcfar� Date� ��`�_Q4� BY �.,`;' Q 1
� I om exempt under Sec. 9�, A
K
B.&P.C.for this reason � 3
Plan check fee � �
���e� PLUMBING PERMIT lSSt11NG FEE 5 `[} `�
. Signalure ` `
� � ..� F �
TOTAI FEE �
. Plan check opplicani .'.-`' ` "� °. a � F
SVNGLE fAMILY
, HOME OWNER-BUILDER DECLARATI�N Name � M �!(� r -,( �
I hereby affirm that I am exempt from the Contractor's license qddress - . - i
� Low for the following reasort(Secfion 703i,5, Businesa and - _ _,_ -
Professions Code): Ciry Tel.No.
� - . . �i:. -:�.. (
4,as owner of the property,wiil do the work and the `'�'
' strudure is nat intended or offered for sale(Section � �
7044,Business and Professions Code�. '� �
'� . CONSTRUCTION LENDING AGENCY - . - :
� 4 hereby affirm[hat there is a ronstruction lending agency for •
� �he performance of the work for which this permii is issued �
- (Sec.3097,Civ.C.). �
� Lender's Name
' Lender's Address
I cedify thvt 1 have read this applimlion ond state thal the j
above informafion is carrect.I ogree to comply with oll Caunty �
ordinonces and Stale laws regulating Plumbing,and hereby [
' a�thorize representa�ives of this Coun�y to enier upon the
� abave- enlioned property for inspecrian porpos s. �
SEE REYERSE FOR EXPLANATORY LANGUA6E
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ig pture of Permittee Dnt
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