HomeMy WebLinkAbout1688A (10) VUORKERS'COMPfNSATIDN DECtARATION APPLICATION FOR PLUMBING PERMIT �D��,� 1 f
' I FPlP.hY pllilT ihai I hovc a crrhflcntc of censert ro sclf �hq��q /�,
insure,or a cer�ilicale of Workers'Compr.nsaiion Insurance, CE BI7(RFV.IOipl) p a�2`' Ll
or a can�fe��d(c�o�py iIhe,re'o!(Sec.3dO0,lob.C.) \ COUNTY OF l05 ANGELES BWLDING AN�SAFETY ``'
P❑olity M1a.�"L`Vp.LLCcmpany ��D�C',�Lllf�A ,. ' ;= '
Cerniied copy is hereby furnished.
fl)R AP�IICANT TO FI�(IN(PR!NT CR TYPE) aUilD��:G �
��Cernfied copy is(iled with!he couniy building inspec- neDRf55 � y S 1
��ondeparlmeN. NU.+ASCR �I%TUREO4ITEM ;T FEE ♦
� �� ��'p -�-" ` LOCPLITY
Da�e '��.n uca�i�1a�Ci.4Sl7�n1 3 WATERCLOSET 1 � �.7�-
pP � � �tFARESi ♦
CERTIFICATE Of E%E.MPTION FROM WORKERS' 2 P.ATtiTUB ` C�OSSST. �bv� �. J � \\J C
COMPENSATION INSURANCE Oi•�NER , �
(This�ecrion n��d no�6�compl�fed Ii fhs work Involred by � S410WF4 �
fhs ermH is lor ona hundr�d dolla.s SI00 or lafs. ����� `
P ( I � ~ Lt�VATpRV � l.D7RFSS
I cerr�fy rhoi in ihe performonce of ihe work for which this
permit is issued,I sholl nol en•pl�y p�y person in ony mnnner S 5'NK CIIY
so os to becomr.subjx:t ro+he Workars'Compensa��on Laws. -D e'S -3�bb
` CISH'NASNF7 � CONTRACTOR ; � \
Dole Applimm r fIOTHESWASHER �O � p,gpqESSb ��
NOTICE TO APPLlCANT: IF, ofier moking Ihis Cxniflcnle o( _
�pmpiion, yo� should become su6jeci io ihe Workeri SW!MM1!!NGaOOLa[CfcTC2 �
Smpe�sn�ion prov�s�ons oF�hp labcr Code,yo�riust forth� 17f ��V�ycaoiNK!Fqcvcrcye. CITY ;� 5 fl �i�.� r��� R
wi�h comply w�ih svch provis�ors or +his permit sholl be N SfqtE ^
deemed revoked. l WATFR HfATER \_ � L�CFNSE NO. � � C1A55 �
IICENSED CONTRACTORS DECLARATION �� DiSTRiC7 rq. avp[E55Fo BY
I hereby o4firm�hol I om Ilcenserl under provisfona oi Chap�er 9 GAS Sv57EM OUilETS' R^ �
(commencing wi�h Secrion 7000)ol Di�ision 3 of�he Bus7ness CuriE750vER � �Z
ond Professiors Code,ond my I+:ense is in(ull(ace and ef(ect. 5 PER SVS7E�n
11 �,] F FINAL ZyALIDATION
Ucense Number y����- 1 L�c.Cioss �3 b DATE 5�� ��7 O
� ��a �C �_� FINA�
Con�rottc� �(r ��j D��e �- BY �
�� �
❑ I om e.emp+�nder Sec. �
U
B.BP.C.for this reoson W
I Plan check fee ,
Datc: Z
I PLUMBING PERMIT ISSU!NG FEE E
Sig�n�ure
TOTAL FEE 1
F�on check apphcant
SINGLE fA.MI�Y
HOME OWNER�BUILDER DECIARATION NomP �
"•ereby of(irm i4at I nm r,vempt 6em�he Conhac�ar's licanse Add•ess
� �!cr!Fe!^!!o�+.•ir.g rr.vs.^.n(Sc;'ion'C31.5, Busir.ess and
ofessions Codn): Ciry TeL IM1o. r� (:�f��i
❑ I,as ownar o(�he properiy,will�lo the wnrk ond rhs
s��uc�ure is noi iNended or off=red for sn!r. (SeUion , ,', • e . e •j
7p4e,Business ond Pro(essions Code). � " I � !..�)n
CONSTRUCTION LENDING AGENCY
I hereby nffirm ttia�there is a conslr�clion lending ngency fer � .: � � ?�i��
rhe pe�{o�monce oi ihe work fer which this perm�i�s iss�ed
(Set.9097,Ci�.C.j. � �'�.il:'.�U�
� Lender's Norne
lender's Addrr,ss
I ce���fy t4of I Fo�e recd rhls ccplico!�on nnd s�a'^�hot ihr. ,
obo�e inforr�a!ion�s corr�cr.1 ng•ee�o comnly wi�h nll Coonry
ordinonces and Sta!�i�ws ren����+��ri„mhi�q,ond hereby
ou'Fcrizc rrpreien'otives oi�hfs Couniy�o n .., upon itic
obovr-m�nt�o��d prep�ny icr i�<�.�cr�on purposes.
1`-yr��� 1 � � �\ � ( SEE REVERSE FOR EXPLANATORY LANGUAGE
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