HomeMy WebLinkAbout1687A (10) ti-ORKfRS'COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT ����+" l� �
� I hereby nfhrm rhni I hnve n cendimte oF mnsent!o selt
insure,o�o cer�iFica'e o(Wnrkers'Compensation Insurnnce, �F A177�FV.�OiAI� p �� `G
C�O CP.�ti(iBf�[Ary IFtPlCOI(SP:.3NJO,LOiII.C.� CpUNTV OF LOS ANGELES BUILDING AND SAFE?Y `1
acYN°1+�-�,,,-1�Company � 1 na1 P_�LIhC�. _ .
Cenified copy is hereby fumishPd. Ru�;D•NG/)- 1 1 � �� 1 �
FCYi APPLIC:•NT 70�RL iv��a!Ni CR TYPE) L •
�Cer.Yied conY�s filed wiih ihe coun!y ba�d�ng inspec- ADcvE55 ( �-] lV e
Iion depa��m�nl. hUMBFR FIX7UQE O4ITE.N � FEE \
/�_� � .,�� ��Q� �� ^ LCCALITV
�o�el]—�LLAppl�ca�i 2� �,( W4iERCLOSET 1 0—.4^��
IyEARESi �
CERTIFICATE OF ExEMPTION FROM WORKERS' � AATI{T�g , CRC55 ST. �
COMPENSATION INSURANCE C'h•NEFI� C �
(This�acfion nwd not b�complNad Ii fhs work invalr�d by SHOwEe ,� ;��
Ih� �mdl I�for ona hundred dollon SI00 Or Issi. MA��
P � ) I IAVATORv � —�" ADDRE55�
I cenify thor in rhe performonce o(rhe work for wh�ch�h�s �
pe�m��is issued,I shall not empl�y ony perso�in any manner 1 S�NK C�TV �- �` T 2�.'
so as io become wbjnc��o ihe Workers'Compensouon laws. ��n
' DISHWASfIFR � �CNTRA�iOR�r ,� � � S
Do�e Appl?mnl ` CIOTHESWASu(R -� e,CDRESS
NOiICE TO A7VlICANT: Ii, aNr rnakinq IhiS Canrf�coie of 5`A'IMMIYGPOOIRECCPT04
�mpi�on, you should kxcome cubject �o the Workms' CitY \ 7 r�E
mpensn�ion prov�s�ons o1+he Labor Code,you must fwlh- ��v;N�!hrirqcycr�M. `Je�S\1��f i 1rf: 1'i��'�� R 3-R �
wi�h comply w rh such previs�ons or �his permit sFwl� bo
deemed revoked. �� STA�E ` �.
LICENSED CONTRACTORS DECIARATION ''�'4TfRHEAifR "� _ �, L!CENSE NO. 1 C�nSS �
19 D�SiRICT NO PROCFSSED Bv
I hereby affirm thot I om I�censed under p.ovisions oF CMp+er 9 � c�55v5rEm OU7tET5 � 1 ���
(comr�ancing wiih SeUion 70pp)of Division 3 of�he Bus+ness L`uiiEi50vFR
o�d Pro!ess�ons Code,and my license is in ivll force and eHec1. 5 PER Sv5iEti1 FINAL
/� �7 � VALIDA710N
-Z�-t �-
Litense Nvmber � Lic.Class_.S_.,'�.32_ �ATE n-.
i ` `� O
Y� �,{th S FINAL O
� ControdorQ �1 P.r Da!e.�.� BY u f
I ❑ �
I om e�ampt under$et. O
W� B.6P.C.for this rnnson plan check fee , a.
� �a'^ !n
� PIU.MBING PERMIT ISSU!NG FEf 5 ` Z
I Sig�awrr
�
TOTAL FEE
Plon check oppt�cant
I SINGIF.FAMILY
HO.ME OWYER-BUILDFR DECLARATION Name
�� '�ereby afhrm rFni I�m r.xempl irom the Comm:�or's Lice.ns^ Address
�,��,rtie r��i�..�inp rc^son�Sc�ion 7Q31.5.Business ar,d
� ' ulessions Code): Ciry Tel.No.
I � I,as owner of the oroperiy,will do 7he wo�k nnd tti!t
s�rucrure is nn� imended or effered fer salr. (Snction ► ..� ��r�'�
704d,Business nnd Croiqss�o�s Cede).
CONSTRUCTION IENDING AGENCY , • e e . o�j
I hereby nfiirm iho�ihare is a cens!ructinn lendinq o�r.ncy for
ihe pe�fo�mnnce of the werk(e�whlch ihis permlt�s�ssued � ^ � (}(}.�Q
(Sec.3097,CIv.C.).
^ i i;1.J(;�
Lender's Name 4
0".L�:.-8G
Lender's Address
I cer�Fy ih��I have read�ti�s aFPl�ca��on�nd s'n�?thar thr. ►
nh,ove ir(crmo�ion is to�r�ct.I nqree!o comply wi•h all COunly
ard��a�ces and S�n�r lows re�ulotin�Plumh�n�,�nd hereby
ou�ha�:e rep�esento�i�es of ih�s Coomy to Pnter upon nc�
ebov=�r�ennonr�prr.pe•ty fer�ns;,ecr�on purpo•es.
SEE REVERSE FOR EXPLANATORV LANGUAGE
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