HomeMy WebLinkAbout1689A (10) N'ORKERS'COMPENSATiON DECLARATION APPLICATION FOR PLUMBING PERMIT 1_����.d {�
. I here6y afl�rm thot I hove n cert�hcat>ef cansr.nt io sr.lf �M1pµ7A � 0.��� L�
insure,or o cer�ifico'e ef Workers Compenxolion Insuronce, CE P.17�REV.10/81�
or a certi(ied toQpy ihereef(Sec.3A00,lnh.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY G
FOoI��tyNo. 1��' Company ��C��E�V1`f1� .
Cer�iFie�!copy is hereby furnished.
FOR APPLICANT TO fILL IN(PRINi O4 TYPE� eU'ICiNG
� Certified copy is filed wiiti�he counry building inspet- hDCRE55 \f � �
tion deporlmer.t. NUMB"r4 FIX7URE OR RE4l R FEf �«A�ITY `
Q �� p� WAiFR CLOSET
Dote��Appliconi�_�ti�f.!��1^MS � \ � NEAaESi `
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BniH iue C4055 57. � 1 �
COMPENSATION INSURANCE r� � C'NNER � � �
(Thi���eflon n��d no�6�compl�ead il�h�work involvad by L S�OVJfR
MA:L 2
rh�p�rmit is for on�bundr�d dollars(f100)er I�ss.) LAVATORV r qD'JRE55 a1
I certHy�hai�n the pe�Io�monce of ihe work for which rh�s 1
permit is issued,I sholl no1 employ ony person in any ria�ner S�NK _ CIfY h El. �
\
so ns to become subject to rhe WorMers'Compensation Lows. � C�SHWASHER
CCNTfiACTOR
Da`e �Applimnl CLCTi+E5WA5NE4 � qDDRE55
NOTICE TO APPIICANT; If, ohe� mo4i�g rhis Certifico�e of 2r Sw�.v�M�vGa00LttECEaTOR � (�
1'mp�ion, yov should become subjecr io the Workers' /[.! �irYQ�� � A 1 n Q'��r- p
fmpensallon provisions ol ttie Lobor Code,you must forlh- �Aw^!SaR!^!K!ERSYS?EM --L11��� 1--�++-��L��u-' -"��?
winc �omply wi�h such provisions or ihis perm�t shotl be STaiE � i��
deemed rerokad. , WATERHEATfR 1 LICFN$[Np CIA55 ?j�
lKENSED CONTRACTORS DECLARATION� �� ~ D�S?o:T r�0. P ESSfD BY
I hereby affirm�ho1 I am I�tenaed�ndar prov�s�ons oF ChopMr 9 1 C'�+S SYSTEM � OUTLETS b ,� O
(tommencing w�rh Sac��on 700p)of Divis�on 3 of the Business puTIF�SOVFR
and Profeuions Code,and my li[ente is in lull lorcb and effa[I. 5 iFR SYS7EM FINAL VA�IDATION
LicenseNumber'1�,�1i� Lic.Class c�n DATE C�_ £�rt7 O,
ConiractorR �D.1f)si'Sb�nS Da�e�"2���b aYA� �'
I � O
I am e.empr under Sec. U
I , B.BP.C.icr Ih�s rxason W
Plon chetk fee ► cL
ID�•e� P�UMBING PERMIT ISSUING FEE S Q �
I Signarure
TOTAL FEE �\�SQ
i Flan check oPPlimm
5!NGIE FA.V.!LY
I HOME OWYFR�BUItDER DCCLARATION Nnma
'4�reby nf(irm�het I am e.rr�nl(ro�n!h�Con�roc�or'S l icens= AdrirP55
? for Ihe(ollowing�eason�Section 7031.i, Businncs ond
� S(r.ss�ons CodcJ: Ci�y Tel.No. :�� U��i�
❑ I,as own�.c(nc�pro;rny,will do ihr wc•k a.^.d!hr. : R � '
s'rucrure�s noi in�end=d or oilered fnr sai�(Sr.cricn , ' � � �
7044,Business erd Professions CeJe). I , 1 C v�
CONSTRUCTIO'J LEND�NG AGENCY
I hr.reby nNirm�het ihr.ro is a mns�ruction Icndinq o3ency for n > j � ),�;\j�
�he performance of the wnrk for which this pe�mit is isxued
(Sec.3797.Civ.C.). �`!.r/:;-�6
Lende.•s Nor�e
IPRf�PI 5 Ad(�lP55 �
I cernfy�hot I ho��read ih�s o^pl�col�on ond sta��+hoi ihe ►
aF�ove mlcrm�tic�is cer�rc�.I or,•r�lo comply with nll Coun�y
erdinonces cnd Stn•�Inws reguln�ing Flurib�ng,and herehy
au�ho•i:c repreienia��ves ef ihis Cnumy io r, r.r opon ihe
abo�e-me���o�r.d rocpo,� Io,i�snra�o��v,nnsr.s.
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