HomeMy WebLinkAbout1057A I � WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMlT / �v � � (
!hereby a4firm thal I have a cer�iFica�e of wnsent to self 7pA667A �
� insure,or a cerlificote of Workers'Campensation Insuronce, CE 6U(REV.ID/81)
or a certified capy th'eof(S 3800,Lab.C.) COUNTY OF LOS ANGElES BUILD��G�AI�SAFETY ////�
7olicy No. �o y J
❑ Cerrified cop� e nished. eWtoING �/ �'`
QFOR APPIICANT TO FIIL IN(PRINT OR 7YPE) pppRE55 .�7�� U / �
Ceriified cop is le with rhe county 6uildirtg inspec- �yUMBER FIXTURE OR ITEM /� FEE
tion deparlment. � LOCALITY
pnte Appli4ant WA7ERClQSEf NEARESi .
CERTIFICATE OF EXEMPTfON fROM WORKERS' BATHTUB �- CRO55 Si, tL �
COMPENSATION fNSURANCE SHOWER OWNER ��
(Thts sottion noad uat ha wmpktad 1!1he wcrk ieralrad by MAI[
u
thv pKmif is Eor on�hundnd dollws(f100)or las�.) tAVATORv nODRE55 ��'/�'�`�' �
I certify that in the performance of the work for which�his . ,
permit is issusd,t shaFt not employ any person in any manner SINK CtTY TEL Flll.
so os to become su6jecl to the Workers'Compensolion Laws. DISHW0.5HE¢ � �
CONiRACTOR �
ppte Applimnf ClO7HE5 WASHER �E� _ t
i NOTICE TO APPLICANT: If, after making this Certificate of �
Ezemption, you shou�d become sobjeCt le fhe Workeri SWIMMlIJ6POOLRECEPTOR ��f �- -
Com nsation rovisions of ihe Labor Code,yoo must farth- C?�' i"' TE� .3���j
pe P LAWN$PFINRLEF 5�'ST�M ' F
with comply wilh wch provisiom ar lhit permit shall be � - 57aie . � - ' � /
deemed re�oked. . WATER HEATER f � LICENSE NQ. ,. Z- SS . O !
LICENSED,GONiRACTQRS�ECIARATiON . ' �Q ' ' `OISRIcr�i�o.- � ' �' PROE:ESSEO BY�� - `
- J F�erebyo£firm 4hat_4 am licen5ed�der p�avlsiQns of.Chopter 9_ � GAS SYS7EM OUi[Ef5� "j � " �
(commenting with Section 7000j ef Divisian 3 of the Business OVTLETS OVfR ' ' � �� � �J'�' Y f
ond Praftsaions Code.�arid my ifcmx 1s in iu41 force sr+d efEes6 . - S PER SYS7EM .. . .,. _ _ . .
. . . . .... � _... . ..w.,�. ...,. ..,, �..,. F!NP`! . . _ �
_ E_.__.. .,.� �_... ..__.._.._... �, VAtIDAtiON
:
9_ �� .. � f . . .. - DATE. .,.`.,,� � . _ . .. . .. . . ._.
,_. ... ..y.�.-�'
License Number�.�Z��tic.Closs� . . _ _ - . � . - - . .. . � . - �
. ///j// s � � � � FINAL
Contractor 'V'���`Date " � � � BY ' . O
; .. .. . _. ... ...... .... ... .....: ... .. . . � �
� I am ezempt under Set. � - - . - j; �
, - 8.&P.C.for this reason - -. . ..� ._ . . . ...- �- --'- - -- -- � - - � . . . - - . � �
..._ �.. ,... .. Rfa�check#ea.. .... .�.. . ..W.. _ .,. ,, _. _ ._ ._ ,
_ �_.. . .. � =
.__. ... ..T .__"_ ate_ .. .. . _ __ _ _. � . .__ __-_ _ ._' _.__ _ ._. ._ }
: --- ._f / ;,.._ ---- - --.--PtUMBtNGPERMITi55UVNGfEE$-_
, 5�� � f J� . . _.._ , ,.,..._.�.. ... . _.. _.. _ . .. .... . . � n:c•x� .-- -...., i
� � . � TQTAL FEE ��- �. .. . . �_ �_. . . ,. �
- -.,, - . . . . �- ... __.- . ' - - � _ ... __ - -. ..-- .._ .-_ . . - - - _
. . _.. __. .,. _.._ ._ .. ,..
- . - ._ ._._-- _- Plan check applicair�� . . .... � . . . - - - �- - - '-- -- - -
. _ . ..._ . .. . .
-. -- - � - - -. _ . . . . .... _., .__. �
SiIvG�E fAMiLY '
HOME OWNER-BWL�ER DECLARATION Name , , � v _, +
n
I hereby affirm ihot i om exempt from the Confractor s License p�dress - �
Law for the following'reoson(Se.tion 7031.5,8usiness o^d' . '. ' . .. ... . .."... . . . , . ... .. -. ' -. ..'. . ..` '� ' ` `.,'.x... �
Professions Codej: - . City . . 7et.No. . ` "� � ., :.� �
❑ I,as owner of the properry,will do ihe work and the � � - �'' ' � =" �
sirudure is not intended or offered for sale(Section � � �
7044,Business and Professions Code).
CONSTRUCTION IENDING AGENCY {
I hereby affirm that there is o construction lending agency for �
the performance of ihe work for which ihis parmi�is issued
(Sac.309�,Civ.C.). " _
1
tender a Name (
:� Lender's Address
I certif that I have read�his a lim' d�`tot t�h p}���0� � �
,� obov Y or pee����al►h��Rl6�ir
ordin����l �,a '�f -�' _pti a �
aWho p��nFati�es o t is County ro enrer upon the
obove-menrioned pro^rty for inspeciion purposes.
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