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HomeMy WebLinkAbout1226A . W(hRKERS'COMPENSATION�ECIARATiON AFPLtCATtON FOR RlUM81NG PERMIT i -�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. 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