HomeMy WebLinkAbout1691A (10) WORKERS'COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMITL�'�'��"��, {� �
. I he�eby af(irm �ha� I haoe n rertifica�e of consent to self �bpyy�q ��
ins�rr.,or a ce���f�ca�e ef Workeri Compensetion Insura�te, CE 817�REV.10�81) ^\o-�,�
or a ce���fle'd rc,o�py1�!�,e`�ecf(Sec.3800,lab.C.) COUNiY Of l05 ANGELES BUILDING AND SAFETY �
P�ol�i�Y No.�a-�-Bl\ .�omP��Y����,,�R. .
Ce���Lr,d copy is herehy lurnished.
fC4F�R�CAtiTTOFlLLW�PRitiTO4IYPE� 8�����'�' L� ,`"
�Cert�Fied copy is f�led wiih Ihe county huilding irspec- ACC4F55 —1 \ {
��o�de�° r�pe(m. \ NUMdEB FI%TURE OR ITE.N ? FfE �
-ZV"0 ko ��A�1P r�ra�c»..0 � �OCniiiv'�\
Da�e Appl�coN _ WATERCLOYT NFA4(ST ♦ �
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 B4Ti�TUB � -- �R��ST• �
COMPENSATION INSLIRANCf � " �
SHO'h'FR O'NtiER
(Thi:��dion n��d not b�eompl�f�d if th�work involr�d by l � '
ths ermif i�for one hundr�d dollors SI00 or lasa. MAiL
P ( I � 5 IAVAiORV ADpRES$ .
I certlfy iho�in the periormonce oF ihe work fo�which this
permil is iiwed,1 stioll nnl employ ony Ae�son in any monner 1 S�NK � .� CIiY TFq ' i `1�!1 ur,
C l
so os fo become su6jnct�o itie Woriers Compenwtion Laws. 1 DISHWnS�.FR CONTRACTOR �
1_ 0
Da�e Applico�� 1 CIOTHES WASHER �L+ � ADDRF55 �
NOTICE TO APPIICANT: If, of�er moking �his Cer�ifica�e oF
SiN!MM!VG POOL RECEPTOR
`emp�ion, you should becor�e subjeU to �he Workeri �ity � � ��
�mpensa�ion provisions o}�he Lahar Code,yau must farth- �. �vyyycno�r.�q!cqcvc?cM �� �
'with comp�y wiih suth provisiors or Ihis permil sholl be SThTE 11 � CI`A� ��
deemed ravoked. , WATER HEATFR 1_ � LI�ENSE Np. b
IICEYSED CONTRACTORS DECLARATION �� D!S�R'�T t�0. ESSED BY
1 hxeby aHirm thot I am licenced unde�provis�ons of Chaple�9 , GAS SVSTEM OUTlETS � O �M n
(commencing wi�h Section 7000)of Divicion 3 0l the Business OUilET50vFR ����� ���-��
and Rofess�ons Code,and my license is in full force ar.d effec�. 5 PER SvSTEm FINA� VALIDATION
1�r�,t �1 t DATE �� }
license Nvmber;t le l L Lia Closs� S �� O
FINAL U
Con�roc!or����l_T����aDo'e '�— �� BY �
� O
I om eKampl under$ec. F..
U
B.BP.C.for�his reason W
Pian check fee ► c
Date: �
PLUMBING PERMIT ISSU!NG FEE S Z
I Signa�ure ��
TOTAL FEE
Fl�n check app�icont
SI":GIE FA.".".!�Y
� HOME 0'NNiR-9UILDER DECLA4ATION Name
��plp�j�r CIf�IM IF;]i I O�A�PT71 FfOT ItiY Cenrmcre�s license q��rres
rfur il•r. foliowing n,rn<.on(Section 7031.5,8usiness and .
o(essions Codn)� Ciry Tel.No.
❑ I,as owne�oF�tie prepe•�y,w�ll do�!,e wcrk ord�tic
!��uclure is not inten�ed er eifered fe+r sale ($ec�ion ► '� �'�.� rt
70d4,6usinr.ss and Prcfrssions Car1r.).
I CONSTRUCTION LENDING AGENCY !•^ ° • • •`�
I hereby nffirri Itiol ih�re is n corsfruclion lendinq agency f�r .I � � C�J O
ihe per(ormon�r,of ihe wo.k(c�whlch ihis p?�mii Is�5sued
(SPc.3^97,C�v.C.).
- � ° � �'J C...:��
lend�r's N�m� ij'.C:]—f2(�
lendcr's Address
1 cer'�ly ihol I hnve rced this npplim�ion ond s•n�e�h��the ,
a6ove in!e�m��ion is carett.I agre^to co^�ply w;•h�!I County � �
crd�nances ond S�o�c lows renul�urg Plumb�np,r.nd herPby
nWhoriee r�prcinnbuves ef�h�s County!o nrter upon ihe
a6e�e-r�eni�en=d prcp=�ry for�nspeU�on purpcs^s.
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