HomeMy WebLinkAbout1692A (10) . N'ORKERS'CO.MPENSATICN DECIARATlO.'J APPLICATION FOR PLUMBING PERMIT ����Zz �
I � I Fereby a`firm i�,a�I hove,o ce��I(Icote of consen��o seli �aqO67A �` t-{
� inzure,or�cer�ifica�e c!Workrrs'Comprtnsntion Insvronce, CE 817(4EV.IOiBI) � ���
or o ce�i�(fIed Qcepy/�he'reo((Sec.J800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
I P❑olicY NO'.00��41y�Company ���,��C-� ._ . � , .
CerY(ied copy�s hereby furnisheJ.
FO4 AF.'IIUVT'O FILL IN(PP!VT CR TV7E) BUIIC'HG L L
�'Ceri�l�ed copy is filed with the co�niy b�ilding inspec- ne�5cS5 . � E
fiondepa�!r+e��. NUMBER FI%TUREORITFM (A fEE '��p��T�
Q ,� \�. (� WAIFRCLCSET ��1 'f
Da�e ��Applirant� y{y�et�lbh� �:AFEST
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB CRO55 ST. L � 1 -C
COMPENSATION INSURANCE Su0'h'iR � 0'NNF� � C � ��
(This t�cfien n��d net b�complH�d iF Ih�work invelr�d 6y ti,A��
�hs parml�Is for on�hundr�d dolleri(S100J or Is■■.) iavnrC2r FD7RF55
I cerlify!hcl in�hr, pr.rforma^:n c!�he wcrl:for which�his 1
parmit is issued,I shall not emoloy nny p�rson in any mnnn�r 5'NK [IiY \� !` .EL��
50(l5�O hflCOTB SUt1�PC��O IhE WC�IfB!S Cnmpensalion Lows. `
` D:SHWASH[R C04TRACT04 S � •�
Do'e A��li[ant � ClOT11E5lNA5HER � ACCR�SS�\, �` l�
NOTICE TO APPLICANT: if, oNer mo4ing �his Ceriifico�e of
-rT p�ion, you Should become subject �o rf+e Wo�kers' � Su'IM.v.'NGYJCLRFCCCTO4
\ f p .�
S pa�sn��o�pmvrt�nns nf iha lahn.Cod•,you mnsi forlh- , c"...' CiTY�\./ \ i' 1"7�1tti� _�
� wi�h com I i�h s�ch pe�mii sholl bc �"`�'���-�"�"RLE45'f$�iM �`
p y.w p�ovisions or ihis STAiE �
deemed re�oked. ,` WATFR HFATER L�CENSf�10. CLAS$
I LICENSED CONTRACTOR$DECIARATION D'STFICf AO F55E�RY
I he�eby aNrtm thot I am litensed u�der provisions of Chopler 9 1 Gn55v5TEM s oJ1tET5 \ � ^(�(\ �M_ n
i (commanc�ng w�ih Sec��on 7000)ot D��ision 3 oi�tie Bus�ness ouliFisovfe ��� .���
and Professions Code,ond my I�cense is in full force and eiieci. 5 aFu SrS7EM FINAL VALIDATiON
I 1`^ �t -7 DATE ��f l�✓ � n�".'
License Number`� 11��`� Lic.Class �J O
\ �� BY AL U.
I Conlracto��G�+e�1-�Olns Date t.t,. (..+'
I � I am e.e�A��^�e�Sec. �
U
iB.BP.C.tor�h�s reason Plon check fee , N�
D���� PtUM81NG PER.MIT ISSUING FEE S „Z,�
Signo•ure
TOTAL FEE
Pl�n chetk oppl��ont
SINGLE FAMIIY
HOME OWNER-BUILDER DECLAPATION Nnme
� eby affirm�he�I om evempl fror�the Con+roc�or's License n�a.rss
yr(or 1he}ollowin�reosnn(Sec�ien 7031.5,Business and ' �
ofassions Code)� City Tel.No.
❑ I,os owner of rl,e prope��y,w�ll do ihe wo�k and�i,� �'� �''�•��•
structure�s no��ntended or offe.red fer sole (Sect�on ► �
70n4,Bus�ness and Prolexsicns Code). ��" e • � •::
COhSTRUCTION tEND'nG AGfNCY � e � � ��,�
I heraby nffirm thot there is a mns�rucrion Iend�ng oqxncy(cr
the pariermance c(the wnr4 for which ihis pe�mil is issur.d . ., : � � ; �7 T
. i.
(Set.�097,Civ.C.).
ne�s_s<�,
Lendr.r's N�me � � v V
Lecder's Address
I cr,ri�{y�tict I h�ve reod�h�s e^nl�cof�on and sla'r Iho1 rhe ►
cbove info�r+a�ion is cr.rrccL I agrer.io ccmply with o!I Cour.�y �
ord�nnncr.s r.nd 5'a'e lows reguloting Plumb�ng,o�d horeby
ou'horize represen�a��ves of this County ro entcr upon t!•c
nbo�e-m=�fiened prepe�iy for fnsn^cfinn pu�ncses.
n / SEE REVERSE FOR EXPIANATORY IANGUAGE
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