HomeMy WebLinkAbout1699A (10) ` . ��CRKERS'CO.MFE.'JSATION�fCll1RATION APPLICATION FOR PLUMBING PERMIT� '��-� �
� I herehy n(firm thnt I hn�r. o certi(ica�e of consr.nt�o self �t�yy�p � \
insure,or o certiFicole oF Werk�rs'Compensafion Ineu�nnce, CE fll7��FV 10iR1�
or n cr�nf+ed pce�7py therrnf(5?t.3fl(?0(,�L1nb.-C�.) � ` COUNTY OF LOS ANGELES BUILDING AND SAFETV ���%�~
P❑ol�'cyNo.�6-1��Compony \" \1...�'('.��A�nN .. �
Crr��fir,�1 copy is here.by(urnished. BUILC�NG \
�--�/ FOR t.FPLICANT TO FiLL IY�PP:Nf OR TYPE� 21. 1 1 \ u�..
l/T Cerlil�ed cony�s file�{�.,�ih th�coun�y buildiny inspec- AD�Rf55 '��
I �'"' licn de(�ortment. �UMBiR FiXTUREOR ITEM Q FEE
�..t�� ��5� 3 �«�,��T� ' ��'�
I ppte ADpl�canl W4iCRClOSET r �;[p4E5T ' L
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CERTIFICATE OF EXEMPTION FROM WORKERS' BATH iU8 GROSS ST. I' l � ` (�,
I COMPFNSATION INSURANCE � O'NNEF � � � �
(Thli�ec}ion nNd no}b�cemplal�d if Ih�werk Involv�d by SHp'1.'(R
I Ih�p�rmll I�for on�hundred dollan(f100)or Is�t.) invatO4v 'A.'•It ?�\g i-��j �
AD�RE55 )
I ceru(y�hot in�he per(orman:e eI�he wak for wfuch this J
� pe•m�r is�ss�ed,I shall not employ eny parson in nny mannnr S�NK �. Cii�
�
so as to become subje;t�o!he Wc�kr.rs'Comprns�lion Laws. DiSH'lfASN(R
r CON?RPC?O \
Dole AppiiConl ` CLOIHESWASHCR / ACDRE55
NOTICE TO APPtICANT: If, oiie�ma4ing�his Ceri�fica�e of
}�mption, you shculd betome subjecf lo the Workeri SwINM'NGPOOLRECCFiOR '� � /� (�
.bmoenwticn provisfons of�h�lobor Code,you r�usi ior!h- ��T�h� P S\r 1 . l ��1� ' '� �7
Ih:b"!SPR�^:v,:ER SY:':.1 S1�iE 1 !C.
wiih comply wiih such provisions�or �his pen�it sholl be �
deemad revoked. WATFR HEATER �ICCNSE NO~ CLASS �
LICENSED CONTRACTORS DECLARATION ` p�S�Wi�i NO. P40CESSED Bv
I hereby aHirm tf•at I am licensed undar provisions of Chop�er 9 GAS SVSiC.N �" CUTLEIS / �y ���
(commencing wi:h SeUion 7000)of D�vis�on 3 0(�he Bus�ness L'UTlEfS G`VFR tSJ
ond Professi�ns Code,and my I�cense is in tull icrce ond eliecl. 5 vFR SYS7EM FINAI VALIDATION
DATE �
License Number��L�c.Closs�� n'
` O
Con!rador�`(L�pP�w�-SOt�C Dore '��e_ aIYAL U.
C
❑ O ,
I am exempt�n�er SeC.
8.8P.C.fo�this reoson V
Plan check fee W
I a
Do�e: V1
I PLUM6ING PER.NIT ISSUING FEE 5 Z
S�gna�urc
TOTAL FEE l
I Flon chnck anpi�can�
I SI.'VGLE FA."1�1Y
NOME OWNE�-BUILDER�ECIARATION Nome
•areby o!lirm�ti�t I oM eaerpi iror�tFr.Contrr.;br's Licensrt
i ��,'�r;Fe`o!lc.��ng�eason(Secfion;031.5,o�s�ness and A(�(��PSS
r�eless�ons Codc): C�iy Tnl.Na / n
❑ �1 �%.^�,
I,os ownrr of th?�rop��ly,will�lo th�wo�k ard!he , �J
i strutture is not intended or effered icr sale (Section , , .o a e •
70�E,Business nn�!Prcfrxsinns Cnde).
I CONSTRUCTION LENCIIG AGENCY I • � O O.J O'
I Fereby nff�rm ihat iticrn�s n construction Icrd�nq agency(or •r•.'.,,�-
Ithe pr,rformonc=of�hn work fcr which ihis permil it iswed ° � ���••"���
(Sec 3097,Civ.C.). �t`i.'1i`�1 J
Lnrdrr's Nvm�
lende%s Ad:Jrc<.s
1 cerirfy ih��I ho�e reod�hls eppRcotlon o�d s•aie that rhe ►
ebove inferr�nrlen is ce�rec�.I�gree ro comply w��h ell Coun'y
ardinonces nnd S'n�n lows regulo��ng Plumhin�,nnd hereby
outtiorizc rrpre<.ematives of thEs Ccumy io en!er upon thr,
a6ove-m=niion��prep[!rty fcr inseec�ian purPosns.
SEE REVERSE FOR ExPLANATORY LANGUAGE
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