HomeMy WebLinkAbout1683A (10) WORKERS'COMPENSATION DECIARATION APPLICATION FQR PLUMBING PERMIT '�°f �3 � ;
. I hereby affirm tha� I hwe o cerrifioq�a of consem�o self �y yy�p k����.��
insure,or a cerrif icata oi Workeri Compenw�ion InsuroRCO, CF 817(REV.10/8�1
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or o cen�Ned c o p y�hereoi(Sec.3BOD,1a6.1C.) I C OUNTY OF LOSANGELES BUILDING AND•SAFETY
P❑o��icY Noa�Fa—�t-r--GomPo^Y L7.�Te ,��YI['� ,
�Qrtified copy ie hMhy lurnished.
FOR APPLICAM TD FILL IN(PRWi OR TYPl) BUI�q� I1 ,� / A ,
�Cernfied eopy is flled with the touny building inspeC- �� � VOt�
non departmen�. NUMBER FRTi1RE OR fiF1Y1 � � ..
, �ouun F� �1
Dple Appli�pnl (./ �j WATERC�OSFf
RT 1 TE OF FXEMPTION FROM WpRKERS' 9AiN iUB ���T� h V��i Q
C4MPENSAiIONINSURANC� g��R r aWry�R
(Thls��cflon naed not bs mmpl�e�d II th�werk Invelrad by � �t . .
th�p�rmir 1�!or on�hu�iad dollan(5100)or la��.) Wvnroar � �aas � �ift ,e
I c�n�fy thvr�n rha pertormance of+he wwk for which ihis .
permi��p ia�ued,I ahall�ar emploY onY p�nbn in anY manRer SINK � � C�tv � .Np. - O�
i
so m�obeeome subjen ro rhe Worken'Comp�n�tpn Lpws. a�W�p _ . r
COMRAL"IpR C�
DGiD epplimnt 40TNE5 WASHER b � AOq�Ss
NpTICE I�D APiIICAM: 14, oher making tMs Cemfimte of SW��p�REC�OR O
�mption, yov �h�ld become aybjecv ro the Waken' - �
CiTY
( pensofion prpvia�Om o4 iAp{phw Code.�reu muet fprth- �4WN SPRIIVKIER SYSTEM + �.�. � � .
wdh CwnPly wnn 7uch ppr�gions o� �hb permii shall be SiAiE UC �
deemed reroked. r WATEIi HFATER � 11C�N3E NO. tlASS .
IICENSED CONTQqCTpRS DECIARATIQN DISTRI[�nID. SSED BY '
I hem affirm IFqI I om licensed under GAS SrS�EM �lJf1Fr5 � ��
by prorisions o.f Chopler 9
Immmencing w�h Seclion 700p)of D�risia.n 3 ai�he Business pUTlEiS OVER r �
ond P.ofession.eod nnd �� e�s+n fuu 4orce a� �. s�+�A+ �N EL VALfDATION Q
ticense Number ie.Cims� �L� {� .
FINAt OC
Comrona te,__ BY �� O •
I ❑ I am exempt unde�Sec. � '
I B.BP.C.for this reoson
Plan check fee , ? �
�re� PLUMBING PERMIT ISSUING FEE S
S�qmh�re
TOTAI FEE
Plon chec4 aPPl:wnt .
SiNGIE fqMILY ::� �,�",.1 �
HOME OWNER-BUIIDER DECLARATION Name �
��ereby oflvm tha�I om exemp�from the Con�rac�or's L�cense � �
� �!a!he following;+posor.(Seclior,7031.5,Bus:ngss Ord ��S �� � �" �
�essions Code1: CiK Tel.No. I � � (i�:�j
❑ I,as owner of the proper�y, 'll do rhe wwk and�he
6nucfure is not intendld or oRmed for sole(Section � � a � i ,�/;i;^,_ •
70M,Buainass and Profeaa�ona Code). '
�'�.K.)"��; '
'�ONSiRUCT10N IENDING AGENCY
1 hereby affirm�hor�here is v conrnucrion lendinp ogency fo• ,
rhe peAormonce oi the wpk fw which this permit is iaupd
(Sec 3097.Gv.C.).
Lende.'s Name .
Lender's A�d.ess '
I cenify rhol I hore reod this appl�cat�on and cw*e ihat Ihe '
above informarion is correct.I agree ro comply rv��h pll Coun�y
ordinonces and S�a�e Ivws regulating Plum6ing,ond hmeby
aWhprlte repreee��aiivos o(+his Coun�y to enier upon the .
abova-mem�oned roperly for inspeclion p�rposes.
SEE REVERSE FOR EXPLANATORY LANGUACE
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