HomeMy WebLinkAbout1696A (10) WO4KER5'COMFENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �'�25 � ,
� I hereby n(hrm that I have o cenificaie of ronseni to self �hqby�q � L�j
insure,or o certilica�e oi Workeri Cor+pe�sation Insuronce, �E P.17(vEV.IOifll) �
r.r a cer6iied copy�herecf($et.7800.Lob. .) '� .
,� COUNTY OF LOS ANGELES BUILDING AND SAFETY e��'r
P❑ollcy ho.�Compony .
CerfiFied copy is hereby furnished. BU�LD'NG
�OR APPLIC.4NT TO FI��IN(PRItiT OR TYW)
��Cerlified copy is(iled wilh Ihe[oun!y building inspec- A^GPESS
��on deportmenl. NUMBFR FI7(TU4EOR ITE.11 y?,� FEE
Q��� ��r� —c� \ LOCPLITV�`
Do�e�_ApplicpnlR \(1�P!�#-�Rlr<< �j WATERCLOSET � �;EARFST �
CERTIFfCATE Of EXEMPTION FROM WORKERS' BntH 7U8 CRO55 Si. V� _
COMpfNSATiON INSURANCE � � l
SHCWER OW4ER
(Thi���etion n��d not b�compl�f�d if Ih�work Involv�d 6y � J
ih�p��mlf if for on�hundr�d dollon(3100)ar ba�.J CJ LAVATORY Ma�� _
�- A�DRE55
I cenify iho�in�he perFormance of�he wo.k for whith�h�s .
permi�is iawed,I sholl no�employ any person in o�y monner S�NK b _.. Ci �
sa aa�o bxome subject ro rhe Wor4eri Compenaa!ion Laws. CiS�iW0.SNER
I CONTftACTOR � �
Da�e Appliconl ` CIOTHES WASNER � qDDRESS —
NOTICE TO APPIICAN7; If, ofier making �his Cerlificote of SWiMM!NGFOOIRECEPfOR
pmp�ion, you sF.ould betome subject to the Workers' CiT � t i
,5mpen�otion provisions Of the Labor Code,you musl forth• � ,V � � —
with com 1 wi�h such ovisions or this ermii shall he «WNS°?'NKfER5Y5?EM
I P Y P� P Si�TE I.. (� �
1 deemed re�oked. 1 WAiER HEATER �, LIC.15E N0 CLA55 L^
(ICENSED CONTRACTORS DECLARATION CiSTR::T!JO. OCESSFD 5Y
I herehy oKirm Ihot I ari litented under provis�ons of Chapler 9 � �S SYSTfM OUTlETS ,O �
i (commencinq wirh Section 7000)of Division 3 of rhe Business OuiiE150vER
ond Professio�s Code,and my I�:ense is in fu!I force and effec�. 5 PER SYSTE�n FINAL VALIDATION
License Number���,��� Lic.Class� DATE J^Z I_�� I O
FINAL /� ()
Co���ac�or��R`^2e��b�Da�e�l�� BY �
❑ �
I am e.empt und=�Sec. O
U
B.SP.C.(or ih�s recson Pian check fee , W
Q.
Daee: N
PIUMR�NG PERN,IT ISSUING fEE; ,z
Signoture
TOTnL FFE `
S!NGIE FA���qY �inn check applicant
HOME O'�lNFR�9UItDE2 DECLARATICN Nam�
'tiereby a!firm ihef 1 nm eremnt from ihe Conna<ror's l�cens�
�.!a::ha!c!!::x�rg recscr,($cU�on;07I.5, nus�nrss nnd Addrvss
oless�ons Code): C�iy Tel.No.
❑ I,os owne.o{ihrz p.op�rty,will do�tie wo�4 a�d!he
s'ructure is nor in�erdpd or of!ered i��solr. (SPciion ► ,_� ��G C��
704�,Bus�n�ss ond Prc(essions Cndr.).
CONSTRUCTICN LEN�IthG I:GENCY � � o • e e j
I hereby nffirm�h�t therrt is a cens�ruc�ion lending n�7enty fnr
if�r.pe�formance oi�h�wr.rk ler which�his{�ermir is�ssu^d � • � � �.5 n
(Sec.3097,Civ.C.). �
n e � I /.:.'V:.
Lende�'s Nome �lf V U-��
Lender's Address
I cerufy itiat I tic�e read��•�s cppl�ca��on o�d s�nie�hn1 Ihe ►
abcre infermn��on is cr.•rrct.I o�rrr�o cr.mpiy w���h all Cou�ry
ord�nan�es ond S�a•e lows rer�ln�ing Flumbinq,ond h=rp6y
au�horir^represenio!ives of this Cr.unty to en�er vpon�hc
cbove-�enlionrtd praprrly icr inspr,ction purpcsrz.
� SEE REVERSE fOR El(PLANATORY IANGUAGE
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