HomeMy WebLinkAbout1693A (10) I WORKERS'COM.PENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �u�-�-23 � �
I he�eby alfi�m ttiai I f+ave a cen�f�cm.r of consrnt io sell �bp,y�,�q
ins�re.,or o c=rt�(�cn�e.ef Workers'Comprrsetion Insuro�ce, fE Bi�(REV.10�81� �`�h�
e.n ce���Ned coPy�he�ecf(Sec.3800,lab.C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑ol��cy No�g q-�1} Com,ony�'(��� , ,
Cert�f�ed cepy is he•eby}�rnished.
FO4 APPL�C�NT TO F!ll IY(�R'NT OR T�PE) BU�LDING
�,�i'� Cert�Red moy�s filed w�ih the counry bullding inapeo- �CDRFSS � �,l
licndeportment. NUMBER FIXTUREORITEM �d FE�
1__ \ LOCALITY
�o�e�_ApplicoN� `n�+'�x�yh( � WATfRCLOSET � KEAREST `
CERTIFICATE OF EXEMPTION FROM WORKERS' 2, BATH T�A `
CROSS ST. O� C \ �1.�
COMPENSATION INSURANCE � �
� SHO'NFR \ CWNER \�
(This��dlon n��d nof h�complN�d il fh�werh Invelr�d 6y Mq�� \
th�permlt is lor on�hundnd dollon(SI00)or In�.) � tqVaTOav / AD�RESS
I cen�fy�hai in the perlormonce ol ihe work For which this � $INK CiiY �^
permil is issued,I shall nol employ ony parsan in ony monner - S
so as ro become subject+o rhe Workers'Compensa��on Laws. 1 D'Y+iKASHER J � 1 \
� CCNiRACTOR ,�
Da+e Applicanl � CLOTHFSWASHER � ,�DDRESS
NOTICE TO APPLICANT: If, aftar moking �his Cenifico�e eF
�emp�ion, you should become subjecl to !he Workers' � SWiMM�NG POOL RF:EP70R .
rmpensar�on ov�sions oi�tie Labo.Code, ou must Fo�ih- CIT. �
with comply wirh such provisions or �his permit shall be 1°'NNS�R!NK!EQSYSiE.M SIAIE ` C.
dOOmOdrevoAed. `` WATERNEATER L�.'NSENO. � C;A$$ �
LICENSED CONTRACTORS DECLARATION C,SrR�Cr NO. raOCESSEo ar
I hereby offirm�Fq1 I am licenaed�nde�provisions of Chop�er 9 1 GAS SVSTEM CUTlfTS i �O \ �^^ �
(tommencinq wi�h Sec�ion 7000)of Division 3 oi the Business OUTlET50VE4 , �y�
and Professions Code,and my license is in full iorce and eifett. 5?ER SvSiEm FINAL VALIDATION
`��1�t �a q� DATE t 7 p},•
license Number��,p�`"1 Uc.Closs�� � p
p F FINAL U
Con�.oc�orR ` P��bhS Do�e -� 2�C�81Z BY �
� O
I pl:l BxBMFf U��P.f SPC.
B.BP.C.for this reason W
Plan check fee ► Q.
Dote: �
PLUMBING PERMIT ISSUING FEE 5 Z
I. S�qna�ure
TOTAL FEE
J
Flnn chec4 applicant
51^JGLE Fi1.M.ILY
HOME OWNER�EIU�IDER DFCIARATION Name
"•r,ryhy effirm�hor I em P�emp�frori the Contrnc!or's License q��rrss
. }r fo�14�e following rr.oson�Sec�ion 7031.5, 8usiness and
ofesslons Code): �i�y Tel.No.
❑ 1,rz ownnr of�he prc,^.�riy,w�ll do ihc wc•k a^.d!4e , �-'I f)`.%J r'1
struciure is nal interded o�oftered fnr sale(Section ' �
70dd,business and Proirtxsia�s Cede.�. . e • a•
�ONSTRUCTICN 1EN01NG AGENCY v
I hereby nNirm!ha�ihere is n cens!•utlicn le�dinq a�en_ry for �� ° � I C J Q
ihe per(o�mon�r,of�he wo.k(r,r whicf�iF�is p?rmli is�ssucd
(Sec.3097,C��.C.). ` .• � I �.:)ii::
Lend�r's Nomc
��i��-'b
Lender's Address
I cerfify Iho1 I hnve rend th�s nnp��ca'lo^a^d s�o'e thal the ,
chov!+infcrmoHon rs m�mct.I nq�en ro cemply w��h nll Counry
ord�ncnces nnd S�a�c lows.er,ulo��n9 Flumb�ng,�nd he�eF.y
au�hcnee r�nrc�en�ouves oi iti�a Counly to rtnicr upnn ihc
a6o�e-ment�oned F�ec.e ry for�nsp^u�on�urpe<ns.
� SEE REVERSE FOR EXPLANATORY IANGUAGE
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