HomeMy WebLinkAbout1698A (10) WORKERY COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT� `t`�`L� � �
� I hrrrby ef(�rm�hai I ha�e n cenil+cate of conseni io self 76A667A I��
msure,or a ce�i�Rco�e af Wo�Weri CompensaYen Insuronce, CE 817(REV.10�81)
m o cenifi�edp c/o�p�y�ih�e�ree�(Sec.3800,Lnb.C.) \ COUNTY OF LOS ANGELES BUILDING AND SAFETY �`,A�
P❑olityNo.�T�4 �Q11 Compeny ��Q�r_��-IhC'l _ . . .-
Ce�rf�ed copy�s hereby forn�shed.
FC4 AP7LICANi TO FILI IN(PR'NT OR TYPE) BUI�CING!'� `,
�Cenified copy is fiied wiih!he counry build�ng inspec• aCDRESS L-. M � \
liondepartmpnt. hUMBER FI%1U4EO41TEM R FEE
\ LOCAIITY
Do�e�Applicam����P-f°�Si]Ir�C WaiERClOSET. � NinREST
CERTiFiCA7E OF ExEMVTION FROM WORKERS' BaiH Tue CRO55 Si.� � EW �.Q,
COMDENSATION INSURANCE � �
2 SHO'NFR O'.1�'NER
(Thit��tllon�s�d no1 b�compbT�d if Ih�work Involr�d 6y � MA��
Ih�p�rmit is!or on�h�ndr�d dollan(SIOOJ or I���.J �qVAT05V � apDRESS - �
I cenify iho�in the pe�formance of!he work for which�his
pe�mit is is5ued,I fhall no1 employ any penon In ony monnar SINK CITY 'Z2
so aa to betome subjec�to rhe Wake•s'Compensaiion laws. C�SHWASHER e \
\ b — ��NTQAR�R
Do�e Applicont 1 CLCTFES WASNE4 � AppRE h
NOTICE TO AiPLICANT: Ii, after making this Ce�!ifico�e of
�jemplion, yo� shou�d be[ome fubjecl lo fhe Workers' SN"MM;NG POO:RECE?TOR � �
�ompenwron prov�s�ons of the Lobor Code,you must forth- CiT -' 1 � rTE�.
taWNSP4�Nr�cqcySTCM j���.riP� ,._�
wi�h comply wi�h s�ch provisions or this permit shall be SiniE ��.
deemed re�oked. � WATER HEATFR �'�ENSE NO. L C1A55
LICENSED CONTRACTORS DECIARATION DiSiRiCT ni0. ESSFD ev
I hereby afiirm thot I om litengcd under pro�isiona of Chop�er 9 1 GASSYSiFM .J OUttETS � ��
(commencing wirh$ectlon 7000)of Division 3 0(�he Businxs OuiiEi50vER
ond ProFessions Code,ond my licer.se is in full!orce and effe:�. 5 PER SYSTEM FINAL G� I VALIDATION �.-
I (}` ^ DATE 7ic,�-� 7 a,
License Numbar� `1� 1� lic.Class� �
Conrroctor
���P-f'Y�L1h�Dn�e 'Zb�4 BY AL � U
v`� C
� O
I vm e.empt under$ec. �
B.BP.C.(or�h�s reoson yVj
Plan check fee ► p.
I ���P� Pll1MBING PERMIT ISSUING FEE E C�,3 Z
Signoiure ` S
TOTAL FEE
I Flan check ooplimm
S�NGLE FAM�IV
HOME O'NNER�BUILDER DECLARATION NamP
I '�areby nffirm�ho1 I am e>�mpt irom r�e Co�'rec�or's License
I �:+`��t`a?ol:owing reoson�Sec��on;031.5.Sus�ness oriJ Addresz
irofessicns Codr.�: Ciry Tel.No.
� ❑ I,os owncr of fhe.p.op�r�y,wi!I dn 1F+?wor4 ond 4+r,
s•ructure is noi mtendrd er o�fered fnr sa�e �Section ►
7044,Bus�ness ond 7rof�ss�ons Cedr.�. ;'� (�C.`."�
ICONSTRUCTICN IENDING AGENCY � +,e e . e r��
{ I here6y nifirm Ihct Ihnro is n cons'�uc��oo lend��g o;ency f�•
� ihe perfermanc=of�he work!or w!iicti ih�x�r,rm�t is issur.d � ° � � C.�V
(Sr.c.3097,Civ.C.).
' ' I i
Lender's N�me `:�,.�.
Lendei s Addre!s r�.'l;ti"Ci:)
I ce•tify:ha�I Fovo reod ihls ar.n���r.!�on cnd s!a�?il+ai�hc ,
abo�e in}crm��ion is cerecl.I on•�e�o romply wi•h r.11 Counly
c�dinonces and 5•a�=Inws rer,ulohng Flum6mc�,crd f•nreby
no�tio.ixe rep•eieNr.lrvr.s eF i4is Coun�y�o en�rr u;.cn nc�
cbove�mnntiened prepeny fer i�spec�ion purpcs=s.
SEE REVERSE FOR E%PLANATORY LANGUAGE
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