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HomeMy WebLinkAbout1306A (7) i 4 WORKERS'COMPENSATIONDECLARATION AppLICATION FOR PLUMBING PERMIT � nnb��,nfLrm tMl I have n ranii¢o�e of�onsnM to self 76�B7A ,�e,cr n(er�ilico+e o(Wdkers'Cnmpe�sa'ion Insurnnce, CE B771REV.B/86) � 1cam��ed copy thareof(Sec.3800,tab.C.J COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS P❑of�icy Na. Compony • � Cer��fied copy is here6y furn:shed. ❑ FpR AOO�ICANT TO Flll IN(PRINT OR TYPE� �p�� /8 ST. �'✓� CT Ce�nfiad copy is f�led with t��e county 6u�ld�ng inspec- ��o�depo��me��. NL'hABER FIXTURE OR ITEM � FFE �«p�ITY Dl�'���� ��J Da�e Applitonl WATER ClOSET NEAREST / . �f 4 • CERTIFICATE OF EkEMPTION FROM WORKERS' BnTN iU8 «C155 ST' 4��'� C�v COMPfN5ATION INSURANCE Ownrt4 ��l' ��j��� (TAi�+�dlon nNd ne�M rnmplN�d if Ih�werk Involr�d br S+OwER �/�.p� �ha p�rmH is for oe�hundnd de�lan(i100)or �.) lavqroar ��� ���� �� /(pU�� ADDRF55 I cen�(y�hot��rhe nerTo.mnnce o(the wo whkh th�s permif is icsued,1 shnll noi emploY ony in any manner SiNK .� CITV D/��� TEI.NO.��.- so os m become 5�6;et1�o�he Worke so��o ows. DISMw,sSNF.R ����� CONTRACipQ Date Appliton CiO1HES WASNER NOTICE 70 APMICANT� li, of r �ki� i Car Kale o A�� ' Exempnon, you should beco wbjeU o Ih Workers' SWiMMiNG POOL RECEPtOR , , Comuenwr�on wovistons of�he Labor Co e, mux�forth• ��T� � ' h���' LAitiN 57ki1�.KLER SVSTEM wi�h comply wi�h such provisions or � erm�i sFwll be STa7E uC. c�eamed reroked. WATER HFATER ������ �5 LICENSED CONTRACTORS DKLARATION dSTR�CT Fk�. V�IQCFSSED B� 1 hereby offirm tMl l am I�censed under pior�sions ot Chcplr V Gn5 SVSiFM OUTlEiS ' \\ (comme�c�ng wi�h Sectlan 7000)o!�iv�sion 3 of the 8usiness p�i�FiSOvkc `������ ond Roiess�ons Ccde,ond my licerx is in fuli force ard eff«r. 5 vER�STfM ��/� � FINA � ��J VALIDATION 0 /�11 � DATE Licanse Number l�c.C�ass ���r���s �� U FINAL � Convanw Daie BY O U � W I om eaempi u�de�Sec. d B.Bo.C.for ehis rsaun q Plan check fee S 2 Dn�s: p�UMBING pERMIT ISSUING fEE S I O O Signniure � . TOTAL FEE I�O b , Plan check appliconi . SINGLE FAMIIY HOME OWNER�BUILDER DECLARATION Name , � I hereby ofi�rr�tho�I om e.empt(rom rhe Co��rac�or's Ltcen�s q��esc ' Law ior tne iollowing reason(Section T031.5, Bus�nesa and . � �essions Code): G�ty Tel.No. . . � � I,as owner of the properry,will do ihe wo�4 ond�he , c. � ;;�b ri s'ructure is not In�ended w offered for sale(Sec�ion 70e4,Business and Professio�s Code). „ CONSTRUCTION LENDING AGENCY � " " � G;]� I hereby offirm rhai rhere ie a conshuttion lending ogency ior �he performonce of the work for whith�his permit it�u�ed • " • � ���T (sec.3097.Crv.C.). •'" ��.i._—.,% lender's Name lender'c Addrees I ce�t�fy�hot I I+ave read rh�s opplicarion and s�a�e rhof the ► above in{ormo�ion�e tarect.I agree�o comply wirh all Couny ordinance nd$�ote lows r ulo�ing Plumbing,and hweby au!hori r esen�o ves �his Coun�y io enter upon the � obov m ed tor in c�ion por0os . q� � SEE REVERSE FOR EXPLANATORY LANGUAGE \ � `�aroture ot Ger ee Do�e / I I � I I I � I j • ��1i•'� I 'T � I;��-. �''.'. l,I��IL1 �`I i 7.{ ���n y.�i � I i � � i , I i I I i . 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