HomeMy WebLinkAbout1700A (10) VVORKERS'CO:'�FENSATION DECtARATION APPLICATION FOR PLUMBING PERMIT��'�`Z�` {� �
• I hereby nffirm ihm I hme a cen�(�cae of conseni io self �y��,y�� O `,
in.ure,or n ce��ifica�e nf Vlorkrzrs'Comprnsalion Insora�ce, CE PV(RFV.IOiB1)
p!(]CV(�ili9(I CO/��IY��IHllPCI�SP[.3BOO,LOJ.C.) ` COUNTY OF l05 ANGELES BUILDING AND SAFETY ��D-�_\ •
P❑ol'�cy No.' `'1` 1 Company ��(L�P�urir, . ,
Cenif�ed copy is hereby iurn�shed.
FO4�PPLICJINT TO FILL IN(PRINT OR TVCE) GUILD!NG � (� 1
�Ce�!�fied copy is(iled with the co�niy buildir.g irspet- ACDRfSS J �
tian depa!Imenl. hUMBiR FIXTURE O41TFM � FEf �
� � 8� �\ LOCALIT
Do�e �� AppGcam• �A�Q��ShL.0 WATERCLC:kT ` ^ �'cAREST � ` � �
CERTIf!CATE Of E%EMPTION FROM WORKERS' Z BATH TUB CRO55 Si.Lb�C�!�Q.�J 1)t-1 J
COMPENSATION INSURANCE OwNER � �
(Thl��aHion ne�d no�b�eompla��d I(�h�work involrad by Z SHOVr'°4 � 1\' S
th�p�rmif I�for en�hundr�d dollan(SI00)or I��t.) lnVnTO4v M,���
ADDRE55•
I cer�iiy�hot in ihe performonce of rhe wa4 ior which ihis '
permil�s issued,I sholl nor employ any person�n a�y monner SINK b CITY
so ot to become su6jeci�o�he Wo�ke.s'Compenso��on Laws. S�`
1 D�SHWASHER .— CONTRACTO �
Dole Appliconl 1 CLOTHES WASHER � — qDDRE55
NO110E TO AVPLICANT: If, oher mokinq this Certi!icore oi SW�MMiNGaOCLRECE?rOrt
�emp!ien, you should become subject �o ihe Workers' GiTv � \ iFi '
.Omppn6ofion provitipn5 of Ihe Labor Code.You m�it forth- LOWN S�4'NK!E.'cvcrcy� � y �
wiih compty wiih such provisions or �his permit shalt he SiaTE R i�.
deemed�evoked. � WATER HFA7FR 1 LICENSE NO. \ L- CLA$$ �
LICENSED CONTRACTORS DECLARATION o � D:SiR;Ci NO. OCESSED sr
I hE�eby offirm�hol l om licenaed under provis�ona ol Chop�er 0 GAS SVSTfM OUTlETS ��
(commenNnq wiih Sectlon 7000)of D�via�on 3 ot ihe Bus�ness Our�,ETSOvER
and Professions Code,or.d my licanse is in full force and eFfec�. 5�rt Sr57eM FINA� VALIDATION
3 DATE �
license Numbar�.l�'�L�_Lic.Class� 'S��z �7 p
�l\C� r\ � FINAL U
Conrrac�cr } P. .V SCht Dn�e '6 �'� BY
K
❑ I om e.emp�unler Sec. . �
U
B.BP.C.(or�hfs reoson W
Plan check fee . , 2
D��e: cn
PLUMBING PFRMIT ISSUING FEE S 1G Z
SignoiurP �'
TOTAL FEE
I Flan checi opplican�
5!NG!E FA.".11LY
I HOME OWNCR�BUILCER DECLARATION Nnmr,
'4=roby r.lfirm!Fcf I om erempt lrom Ihrt Conn��!or's Licans?
. j..for�hr.foiiowmy n.a�on(SFclion 7�3i.5, nusinrss anu Address
rrc(essions Cod��; Ci�y Tcl.Nn. . � %(j.(���.
❑ 1,as own�r c!itie prcp�rrY,will do th!r we•k and!he � ,
shuclu�e is not iNendrd or o(}^rrd(nr snlr (Section , r.• a s . •�
70aa,Bus�n�ss or+d Prcfess�ons Cedr.). I a , j (,;`�
:ONSTRUCTION LE��ING AGENCY .
I hereby nflirm!hnl Ihr•e is o conslruclion Ien�!in�o�ency 1or s -„�
ihe perfermance of ihe work for which�tiis p?rmd i5 ISSUCfJ
' � I i�.:)i,;:
ISec.�^97.Civ.C.). � �l'(1 i'��i�
LP.n(IPi 5 N�TC
tertder's Address
I ceri�(y Ihnt I hovr.reod iti�s epp��cnaon and srote thot rtie ,
r.bo�c infcrm�tlen is cermcr.I r.q�ce�o comoly w�•h c'I Ceunty
or�i�nnnces and S�a•�lo+vs rr.�ulotinn Plumh�r�,cnrl hcreby
a�'hori:e represr.nto!�ves c!this Ccun�y to e��^r uc^�!I^e
obo�r..meni�aned properry fer insp^c��on purncsrs. SEE REVERSE FOR EXPIANATORY IANGUAGE
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