HomeMy WebLinkAbout1152A (5) WORKERS'COMVENSATIONpECLARATION APPLICATION FdR PLUMBING PERMIT �
I here6Y aiiirm rhat I houe a cerWficara of consent ho self �6A6y�p
insuro,a a certificale of Work9n'Compe�sa�ion Imuronce, CE 817(REV.t0i61)
o��y�ni�d cgpy�i�e�o���b�0-0 c) � 1 GOUNfY OF LOS ANGELES BUILDING AND SAFETIf
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P�ol'icy r,'o.d' S t �� mPa^Y •/"f4 �as . .
CO��ed mpy is hB�eby furnished.
[]�cernt�ee oovr is filed wiih�na�o„�N tn.�id��g��aa«- �+awucayr io F�w roawr«e rrv�� Aeo ��.j.l'ol.� -�J�'u����/afs: n�.
nvn deP�m Nun�fl+ wRUR[on nFM A �fF I}y '.
fNAIERU.O6ET ���ltt ��d??tPAI �VR�
DoM �f' . MP��Wnf �-� �� NEA T . ._. .. �
IFI�qJE OF F�fflulPllON fROM WQRICERS' BniN iUR �. • �'Z� �C. +
CpMPEN$AlION INSURANC� S�R OWIVER /Yj�- u /y.G h �
(Thh s�e►Jon nsed not 6�eompi�Nd Il tho vrork imolnd br ��� ��M 4 �
th�pstmlt H ior en�Hvndr�d delfem(f100)or I�n.) tAVATORV
I a►nity{hpr in fiv perlormance af rhe work far whkh th�i - . . . . ..
perthit iY i5sued,I sfqil nof empfoy any penon in ar�y manrrol � CITY �' s.s�,• TEL.Np. �
�o m ro fscome mbjec+ro�he Wa4en'Campema��on lows. �/ �
DI�IWASHER GpMRq[TOR �`�f•��OI.2�+��lsdM
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Duro � app{itant EtOT1FS WASHER +
NOflf��D APPLIVW�:1f,aher making�hia Cenlfica�e of ����U � ���ay
EKemp�ion, ►ou ah�u�d become sVb1err m M�e Nvwkan• sw�nnmo,IG vaa REf�P�oe cttr /}� ��� y� iEl.no. eI�� i
Compen�lion provisipns oi 7he��ode,{rou must fprth- UWN BPRMIQER SV57EM "� `^' '^'^"' � ' �� �
w��h �ymply v�ilh wch Rc�eeio�or �h�a pvrm+r shall be . -
dae�msd rawkmd. wnrEa rreAtEa s�wo. t� � e�u�s5 L�G,q4 j
uC�lySEp CONTRACf�ORS D£CIARAs10N olsrw�O. , 6 I
I hereby Offlrm Uta1 i EHn Ifeenaed unt�0�O�wi7iWrf of ChoWx 9 GAS 6YSTEN� OUTlFfS '
(commendrq wilh SeCfion 7000)oi Oheieiqn S of the Business OVRF� ' , , j
and f►ofe7sio�a4oda md+�M(iterise ia in 1�II(orcefC� r. 6 vEk �'
f � o�� VALID'ATION � ;
ticense IVumbe. . .!O a 4 ic.c�o9s � `� . V i
F1NqL � '
Contracror �� � Da+e� BV 0 i
❑ 1 om exempt undx Sec. W �
O� �
� 9.8P.C.fw this reawn y �
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Plan check iee
Daee: p�UMBWG PERMIT I$$UINra FEE� �O S� �
Spnow'e
TOTAt FEE �d �
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Pqpn chsck pppiicont
SMGIE PAMhY '�
HOME OWNEk-BUtIpER OEC�ARnTq� � Nome NoZ��cc� L�6i='+� oe1
I hpreby pHirm�F�M 1�OxOmpY{�Om�he Conhuc/w's LiCamO ' �� l b-,b,r� �1 i 5.2 A
Law fa�M follow�ng revson(Sxrio�7091.5,Buai�ess and �$• •,• • •5 .
P'deuio^s COd4Y Ciry . Tel.No. �
❑ 1,m ownm of the properry,w�11 do rhe work and�he � 1 .a 3�'.$0 1
shuch'ro ia not ime�ded a offe.ed ia sale (Secrion I
70M,Budneii and Proteasnzm Codel. • • •3 C.�0�, ' 1
i
COrvStRUCr�OIv IEMDR9G nGEWcr ;
I here�uffirm tha�Ihere is o comhuction lendirg age�y fw �7'G�'8'S ;
�Ae pertom�once of rhe work fa which thia pe.mit ia iewed .
(Sec.9097,CW.C�)� . . .
, 1
t
le�der'�Name ±
Lender'a A�dress .
I certlfy ihyt t hcve rgoA�his applicution and stote mot the �
abovp infomativn is .I agroe�o wmply w�th all Couroy
adirronces and Sto� tirrg Plumbing,ond hereby ;
auiharua rcp , oF�ha un�v io emar upon the
a6ovs.men��o o fa� ��on porposes. �
_�J SEE REVERSE FOR EXPLANATORY LANGUAGE j
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