HomeMy WebLinkAbout1683A WORKER3'COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT �°� �� �
. I hereby aff�rm �ha�I ha�e o cen+f��ate of conaen�ro iglf �y�yaq ���� //�
inyvre,or o cenifica�e ai Wor4en'Compensarion Insuroncp, �8��fREv.i0�81) �
w o ce.tified copy thereot(Sec.3800,lab.C.� [� ` COUNTY OF LOS ANGELES BUILDING AND SAFETY
Paol�icy No.�-��pmpony����"�'�A �/����y� ,
Certitied copy ie hareby(vmiahed. �T T�p
FON APPLKAM TO FILL IN(PRIM OR TYPE� A�� g •i
�Cen+t��copy ie f�fed w�rh�he cou�+y bu�lding�nspx- '
Uon depoNmanf. ` NUM6ER FufURE OR rtEM � FE! ,
�a=�� �, � 3-�Ov�S n�qREsr ,+�
Dote Appl�ton�� n. [r WAIEA C10SfT � .
CfRTIFICATE OF EXEMP�tON FROM WORKERS' 2, 6AR+iuB ��g�� ��n' V � � �
COMPENSATION INSURANCE 2 Oyyn�ER ' " '
(Thb rocllon nwd nof bv rnmpl�hd IF th�work Imotwd by SHpW�R
fh�p�rmit Is for on�hundnd dellars(f100E o��ess.� u�varOpr ���
I cenily Iha�in�he perfarmaMe of�he work for which this _ �D�� �_� i U� .
permi�ia iss�ed,I shall ao�employ any peraon in any monner t S�Mc C�T TEI. �
so os�o become subjed�o rhe Wwken Comppnsafion la.ws. 1 �W�p ` �
�p coNrw►croR �,.�
Dpfe- opplicant � QOiMES WASNER � .�
NOTiCE r0 APPLICANT: If, uAer making�his Cerrificare of Ly AUOR�u .
: 'ynp�ion, you ahould become subjec� �o �he Workers ''V Swww4NC'�Op�REC�°TOp
,Fnpenaarion prorisiam oF�ha labar Code,you mus�fonh- .� �p��1NKlER SYSIEM nrr v Q��f �Ei.Np.
'"w��h eomply with aueh prov�siona or tl�is permii ahall be STA7E /��{� LR.
deemed revoked. warea Heaha �. ��*�� "� 1 Un.Ss
LICENSED CONTRAtTpRS DFLWRAiION q�Onp, � f-QqpCF55E�98r .
� I herebY p�rm IFpI 1 om li[e�SEd�ndQ�pfovisio115 o4GhaplBr 9 , GAS SYSTFM WTLETS ,� \\ :
(commencing wi�h Senion 70pp)of Di.ision 3 of�he B�sineas p�TIF�S pyEp ��'�
and Rofessions Coda,and m liceroe is in f�ll fo.ce and effau. 5 PER SrS1EM y
" oAh� ` VALIDATtON Q
I License Ph�mber��Lic.Class�_ `'Z �G V .
�^ b �S ut FIN/LL � :
Gon�*aclw,... ,1� .f c ev�S Da�e$�4� BY �
�
� I am eaemp/under Set. 6 '
N
I8.8�.C.for 1A�s reoson Plan check fee � ?
Dafa: PIUMBING PERMIT iSSU�NG FEE i 1Q
Signulure
TDTAI FEE
Plan chxk applicant
SINGIE f/1MItY �
HOME OWNER•BUILOER DEC�.4RATION Nvme .
i �'�+�eby affirm thoi I am exemp�From�he Contrauor's Litertee �d��s
�for+he foiiowing revson j5enion 703i.5,Butinets and .
' .,rasiona Code): C��y Tel.No. :. i :`.. �f4 �
❑ I,as owne�01�he proper�y,w�ll do�he work and the :. .. : . : s; �
snucture is not interded o�otfered for wle (Sedion '
7044,Bvsiness and Rofess�ons Code). , j , � � ;:-i ,
CONSTRUCTtON IEND�NG AGENCY
I hereby affirm�Fqr rhera is a conslruclion landing agenq for " � � � ' ^�,'T
�he performonce o{the work irn which Ihis permil is issued �.. �:;
(Sec 3097.Cir.C.). . �,l,.,-i;(,
lender's Nome
Lender's Address
I cxf�fy�he�i ho�e reod�h�s opplcwnon and sM�e ihei�he ►
abo.e informotlon is earaU.I ogree�o eomply w�eh all Coun�y .
wd�nancn and S�a+e laws regulo��ng Plumb�ng,and heraby
aulhaize�epreseMafivas of th�s Counry ro enrer upon the �
above-menhoned pro erty for inspec>ion purposes.
SEE REVERSE fOR EXPLANATORY LANGUAGE
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