HomeMy WebLinkAbout1695A . WCRKERS'CO.M.FENSATIpNCECIARATiON APPLICATION FOR PLUMBING PERMIT�'<�2`-� �
' I hereby offirm thoi I hn�e�<e•�ificoir of ccnsr.nt to self ��qy�,�� � ��
insure!,or o[ertifica'r of Workers'Com�?nsalien Insur�nce, CE AI7(REV.iO�Hi)
or o ceri�(�ed copy thereof(S�c.9800,lob.C.� � COUNTY OF�OS ANGELES BUILDING AND SAFETY ���
P❑olicy No.�L�.CcmPanY�� . � . .
Certil�eJ copy is hereby furnisl+ed.
�CRl.F7lIC�NTTOFI�(IN�PA'NTGRTYPC) e11���'2 y3$ S�, IVe. Cb1.�r
��Ce�1�f�ed copy is filyd wiili the coun!y 6uilding inspec- �CCRE55
�,ondepor�mpn�. NUMBER FI%TURFORITEM ? FFE �afLiT �
Da�e �+'�r� APPlicant�lc�Oe�=�V•1 WATFRClCSET -� hEnPEST I � 1
CERTIFICATE OF E%E.MPTION FROM WORKERS' Pa:ti TUd ` C4055 ST.Lt7 h . ,J �J ,
COMPFNSATION INSURANCE � ' �
5fi0'+Vi2 OYJNi�R
(Thls t�clton n��d no1 b�compl�l�d II fh�vroAc involv�d by �,Aii
fh�p�rmit is For ono hundrod dollan(5100)or last.) IAVATCRv � � ACDRE55
I rertify eho�in�hr parformanco of�he wo�k(o.which�ti�, �n
pe+mit is issued,I shcll not empl�y ony An•son in�ny mnnner � SiNK � CiTr� p i . 2'Z•
SO OS�O 6P.COmp SUh�PCi 10 fhP W�rkers'Co�r.pensaiion laws. �
DISHN'AyiER b .� COViRA�TO �
Dote Appli[onl ` CLOTHiS WASHfR � .
NOTICE TO APPLICANT: Ii, after moking �his Cerlifico�e of �.CDRE55
� m �ion, � $WIM,MiYGPOOIRECEPTOR
p you shouid become sub"ec1 io thr Workers' �
:�mcenso�ion provis�ors of 1he Lakar Code,vou musl forlh- l•wYS�R:�iKLE'wSY$TE�41 CIT � (`�.` ,r
1
wi+h comply wi!h such provisions or ihis permir sholl b^ Sin1E ~��C
dsem9d rBvokBd. WATFR HEATE4 f LICENSE Np. CLASS
LICENSED CONTRACTO45 DfCIARATION C�S1e�Ci!�O Q1�(�CESSEO 9V
I hereby offnm thol I am licensed undar p•ovisions oF Chap�er 9 �pS SvSiFm OUitEiS / �M1 hf� _\\ ^- �
(commencing wiih SeUion 70pp)of D�visicn 3 01�he Bus�ness OUilET50vER �� ����1��h'x
and Professiors Code,and my license is in full force and wHec�. 5 DER SvSTFM FINAL ��, VALIDATION y:
WT,1 t Y�Lf /�-�� DATE ��/ .i p.�
litener.Number {(L�"� l�c.Class_S.c_2k1__ p
t� � � � � Q� FINAL �g� � U
Controc�or��P r W SShCDa•e -�5��^S._ AY (OvvV �
� O
I om eKempl undar Spc.
B.BP.C.for Ihis rensnn � 1'.1 6 4.5 A n.
Plan check fee ►
Da�e: �
Signa�ure PLUMB�NG PERMIT ISSUING FEE 5 � ..y a . �j Z
TOTAI FFE � I • � 1:O.:i O
Plan check oppl�coni
SINGLE F:,h'JLY e ,a � �" ";;j(j- �
HOME O`NNER�BU'LDE4 DECLARATIDN Nnr�r
� reby oHirm�Fa�I e�n�.=m^t frem�ti�Cen!�acroi s Licens� p V�.�.e,5 ��„.�—�j�
�for tne follow�ng.eason(Section 7031.5, 8usin=ss ond
�ofessions Code�� �ity Tel.No.
❑ I,az owr.rr of Ih�prope.rty,will do ihe work and the � a ,_, ���,�, ;
snucture is not in�ended or offered for sole(SeUion , �
70d�,8usiness nnd Professions Code). U'�?li l, ���J
:Ot�STRUCTION LEND�NG AGENCY
I hereby nfflrm iha�ttir.re is a construc�ion lendinq ogency(or i��;C- _��
ttie performante o(Ihe wo.k lor which Ihis p=.mi1 is issued
�Sec.3097,Civ.C.�.
Lender's N�me.
lender's Add•xss
I cer5fy thol I hove ro��ihis o,:plka�ion ond s�are Ihot rh� ►
abeve inle�malion is corrptt.I n�•e��o comply wi!h oll Coun'y
crdinances e�d S�n�e lo.�s requ�a��ng Plumb�nq,nnd he.eby
ouihorize repre=�ntn!ives ef this Co�nly lo enlrr upo�Ihr.
ebove�mentionnd(�reperfy fer inc;.rcf�on�urpos�s.
0 r SEE REVERSE FOR EXPIANATORY LANGUAGE
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