HomeMy WebLinkAbout1684A (10) WORKER$'COMPENSATIONDECLARATION ��q � qpp(,ICATION FOR PLUMBING PERMIT �r �� � ;
. I hereby affirm thai I have a certificaie ol consem to self t ��f
inwre,or o certi�co�e o War e�i Compenwhon Iresuro�Ce, �B�7lREV.10�81)
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o r a c erti f i+e d c o p y�h e r e o i(S e c.3 9 0 0,l a b.C.�(� 1 COUNTY OF LOS ANGELE$ BUILDING AND SAFETY �
Q�YNob�Company�a��j fLc.�.L . ,
Cerrified copy is hmeby iurn�shed. BUil01NG �
Cerr+fied eopy i5 lilpd with Ih0[OU�� bu�1d� �p APPLKANT TO FILI W IPRINTOR fYPE) ,
na ec- ADORESS
r�on depanm m. Y �� P NUM9ER i1XN4E OR ITEM �. � ��' '
{� loGl�7r �.,,� 1
�pfe v�� y� Appli�ant WATER CLOSEf NEAI�Sf 1 � �
CERTIFICATE pF EI(EMP�ION FROM YVORKERS' ^L BAiH Tue
O CRO55 ST. �
COMPENSATION INSURANGE S�Ep OWNER C.(,�. �'� • .
(This��dlon n��d nw b�eemple»d i!fh�.rork tnwlwd by O MAIL
Ihe parmff is fqr on�hundnd dollan(;100)er Iws.) uvniORv � � qpp� ( `
I certi}y tFq1 in the parformonca of�he wark}or which Ihis
pnmif is issued,�shpll no1 emplOy any person in any monner �NK CITV �y_ �
so m ro hecome subject to rhe Wpkers'Compenwfion Laws. aSHWASHEp b o ,
COMRACTOR "�'�1� 1 YC
Dpte- epplicanl ! CLOTHFSWASMER ADORE '
NOTI� TO APPLICANT: If, oftpr mok�ng th4 Cenificote of y1
'mplion, yo� shouid hecome subject ro the Warkars' V SW�hun�NGVOOiRECFv�OR e
❑TY 7H,Fp, �_)
� pRnao�io�prOvitiOns oi fhe LabOr COdl,you mus�foAh- �AWN SPRINKLER SYSTEM �
wuh comply with 5U[I1 QIOYIllpfly or �his perm�� +Fqll be StqiF
deemed revoked. wAiEP HF/�7FP IICENSF NO. �qq$S � � .
UCFNSEO CONTRACTORS DKLARA71pN aSra�Ci Np, D sr �
I heropr aff�rm�ho�I am liceroed undd pro+isions o4 Uopte�9 Gn5 svshm, '� Our�EtS �M ��
(commanung w�th Sec+ion 7000)of Division 3 0l�he Business p��i�pyEp U
and Profeasions Code,and rtry liceme is in full faro ond effaU. S ikA SYSIFM ' y
/ pA� L VALIDATION � ;
��]�����( � (� �t� c.�
License Numbe�l J.S.n L�lk.Cipss `--�+�' `L.. V
contwc�or� �S�►1r•id....i ppte $1L--'R� svAL O '
O ~
I am eaempt unda Sec. W
6.
N
6.67.C.for ihis reoson Plan check fee , ? '
Da�e: ,
PLUMBING PERMIi ISSUING FEE S
Sigrqlure .
tOial FEE �
i
P1on check appi�canr '
SINGLE FAMILV
NOME OWNER�BUIIDER DKIARATION Name
'`��rcby aFHrm tha�I am eaempe fiom rhe Conn«�«s L�cenae
�for:he`ollowir.g reoson($ect:on 7031.5, Bvsinees und �`°ss �
,,�essio�s Code): CitY Tel.No. � � ;�, r
❑ I,as owner oi�he property,w�ll do�he work and�he ��
snuc�ure i�nor intended w oNe�ed for eole(Secflon � � ,. • s . ^ �; '
7d14,Bus�nes�and RoFms�vns Cade). �
CONSiRUCTION LENDING AGENCY �� ' � �'�•�v
I hereby off�rm rhot�hero i�o const�uc�ion lending ogency for _ � ,. �
rhe perfarmonce of the wor4 for which thif permir is is7ued " ��•-� � •- �
(Sec.3097.Civ.C.�.
. , �1...—.,..
Le�der's Name �
Lende�'s A�d�ets �
I ce.��1y rhar I ha�e read�his oppl�ca�ion ond s�a�e rher�he ,
abore informo�io�is calect.I ogrce lo comply with oll Counly �
wdinoncas ond Sta�e laws regulo�ing Plumbing,ond here6y
authoi�ze�eprese��a��res oi�his Co�niy io en�er upon Ihe �
above-mannoned operiy for InspetNon purposes.
n � �� �� SEE REVERSE FOR EXPLANATORY LANGUAGE
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