HomeMy WebLinkAbout1226A . W(hRKERS'COMPENSATION�ECIARATiON AFPLtCATtON FOR RlUM81NG PERMIT
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-�i hereby affirm that I have a certificote of consent to selt 20-0028 DPW 6/67 . � �
��nsura,ar b cartificate of Workers'Compensation Insuronce, 78A667A ��
oi d cerrified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS i
P�o�7cy No. Company '
Certitied copy is hareby furnished. q !
❑ FOR APPLICANT TO FILL iN(PRINT OR NPE) qDDRE55 ZZZ I.�^ �M �N.� �
Cerli4ied copy is filed with the[ounly 6ui4ding inspet-
tiondeporiment. NUMBFR fIMUREORI7EM � FEE
� toa+un ��y+,r..r�D ��`K �
WATER CLOSET ,p
�'e [ERTIFICAiE OF EXE'M7TIAN FROM WORKERS' BA7H TUB � �R�55� ���`� +'��� �I V� �
COMPENSATION INSURANCE OWNER f/
(Thls s�cflon nrd na�M compl�Nd if th�work lavolvad by sHOwER � {J7'�'�g
1ho p�rnrft Is for onv h�MFr�d dol{an(STO�)or f�u.) L4Vq70RY �'�� C r j
ADDRESS I S�S/�7 JM�/F
I certify fhat'rn�he perfo�mance of the work for which ihis �
permit is iss�ed,I shotl not empby ony penon in ony manner SINK ��Ty �, �.,�o.y�r�.� �
eo as�o become aubjecl to the Workeri Compensolion Laws. DISHWASMER
2�� , � �w CONTRACfOR !
1 f��/
Date � �rplicant ��'�� CLOTHES WASHER t
NOTICE TO APPLICANT: If, aiter mpking Ihls Certificote of AD�RESS S'�y�.,�� I
SWIMMING POOL RECEPTOR
Exemption, you should become subjec� b ihe Workers' ,.T i
Compensafion provlsioro oF Ihe Labor Code,yau musf forth- �,qWNSPRINKLERSYSTEM Ci� ����'�� y/, �
with tomply with futh provi�iona or fhis permil ahafl be
STATE LIC. �
deamad revoked. WATER HEA7FR LlCENSE NO. ��q�,5
LfCENSED CONTRACTORS DECIARATION �iSFRFR PROCESSE�BY �
GAS$YSTEAy OUTLFFS �
!here6y nffirm thryll om licrni�d under provisionc of ChapFer 4 '� 3
(tommendng with Sect{ort 7000)of Diviaion 3 of the Business WTLEi50VER �
and ProfYsaions Codi,and my lican»is in full fwce and effect. S PER SYSTEM �INAL VALIDATION F
Licanse Number Lic.Claaa DATE � Q �
FINAL V '
Controctor pote gY O �
❑ I am exempt under Sec. ` �j E
B.BP.C.for ihis reason " `(��r� ��'' a j
Plan check fee � N i
Dats: p�(�MBING PERMtT ISSUING FEE$ �O � Z i
Slgnatun �� 2 C.�,y �
10TALFEE i
�e s s o w j �
Plan check opplicant �
SINGLE FAMILV
HOME OWNER•BUILDER DECLARATION Name I ° c���%:; �
z
!here6y affirm that I am exempt from the Coniractor's License Address c � � "�" �
law for ihe following reason(Section 7031.5,Businesa and ' �� � �� �-�- �
Profeuions Code): Cily Tel.No. n` �� o `
� 082y—�_; ;
4,aa owner of�he property,will do�he work and the �
stru<ture is not inte�ded or offered for sale(Section � .
7044,8usiness and Professions Cade). �
CONSTRl1CTION LENDING AGENCY �
I hereby afflrm that there is o construnion lending ogency for � �
Ihe perfarmonce of the work for which ihis permir is issued
(Sec 3097,Civ.C.).
i
Lender's Nome � �
lender's Address �
I certify that I have read Ihis opplicotion ond s�ate that fhe � �
obove infwmation is carect.I ogree to comply wi�h oli County
ordinances and Sta1e laws ragulating Plumbing,and here6y
outhorize raprelenra�ivea of this Counry to enrer upon �he f
above-meniioned properfy for Inspeciian purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE I
s�'Z��� �
SignaWre of Permittee Date �
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