HomeMy WebLinkAbout0972A WORKERS'COMPENSATION pECIARAiION APPLICATION FOR PLUMBING PERMIT � ;
I hereby afiirm that I hmre a cerri4icate of consent to self �y�y�A
insuro,rn a certffioptp o4 N(orken'Compansption Insurvnce, �BD(Rfv.10iB1�
o�o ternked co +he.eof .3809,lob.C.) COUNTY OF LOS ANGELES 9UILDIN A SAFETY
+��N.�.����Y.f,�r�.1r�. � :
❑, Cerlified wpy is heroby furnished - � �
� fOR AVRIGNT TO FItL IN(PRINT�t iPPE) ���` i
CMified copY is fited wiih ihe couMy ildi i �
IiOn d NUMBER fU(TUIt[OII IIEM I� fFE
IOCAIITV j
WATER CLOSET �
DQ�4 � APP�ii4n1 NFARESf
GERTIFICAIE Of E7(�MP►I�N fli� W17RKER � BAiH TUB � C��.
CAMPENSATION INSURAIV<� � g�ER OWNER d ,
(Th�s sMlon nsad not 6�comp Iqted if 1h�work i Wed 6y ��i
th�piirtJt 1�ier on�Anndt�d dollen('�ibd)or bss.} Uvniqtv pppqE�
I cerHiy ihat in rhn perfo.mqnce af the wark lor which thrs �.
permR i�i,tsued,I sfall na emplvV onY person in rnry monner � air m. _
ao aawbecome subjeca�o�he YVakers'Canpenen�on laws. - �
DISHWASHFF CONiRACtOR 1
Rcte..-�._..Aaalicm.i uor�s wns�a � ;
��O APPlIFANT:1!, q(ter maki�Thia Ce[Mimte of '�� .
, You shvrAd me�mme svbjec� ro rhe Wakon swu�ric aoa�vToa �
�amR�4wtirm arorisiona of�he{abur Gode,rou m�+fonh. orr rei.rac�G����,+'� .
LAYYN SVRINKLER SYSTEM
with L414P�1f wi@� tKh P�O'�'�siOns a•�h�s perini� {hpll be S�n1F UC.
de�d�l'tl�� WA�Ea HEaiEa uCHvSE n0. � CtnSS �
a+��Aerorts oBc�nxnrrou� oarRnrra � r
i hatebr a�dqN am�w�dm a�of t�op�a o r.ns srsr�n+ *�out�rs •,
�f n9+,�Sec�lon ot D+.+s+on�a1�hv 8astne� - onrtersa�+ �� .'�'� �' �
G4ds at�FmytR9�!eA�nfuU#ao�4o�e�r. SPd+6xS1FM . DAA�� I 6 _` VAtIDATfON u :
Licerne Num ic.C�5� - - Oi '
'. - ,.,' � FI �
��y .' .�. Dols '�.� BY � 1
L1 N +
�am exem�undltr .
$.SP.C.for this nearon P�On G�Ctk f6� �� � i
��:�""�"�"`— PLWMQING PERMIT ISSUIIVG fEE S , .
6r0^o�rn° - -
roTu rt�
�Ptqn cTeA aPP�icant " .
SiNGfE PAMiIV .
}� t10ME OWNER�9UIlOER UECIARAcT10H •Nmne �
. ,( yy uifvm tkqi I am exemv�f.om+he famocror'a Ucerne q�rex� f�9 7.�A ,
- fqr Ilfe fullwring�eosun(Section 7031.5,.Busi�s and
Profe�sion�GodO)� ' Ciiy Tel.No. #�� � � a 5
❑ I,m owner o4 the properry,wilt do rha work and the � j
■nvewe�s�e��mm�ded a elfered for�ak(See��o� ► 1 • � ����
7p4r,8w��ees and Frofessior.s Code). '
CpNSTRIKftOW lENDING AGENCY , • • i D 2 G G� '
I herehy off'mm�ho��hero q o comnucNon lending cge�rcy for
�he aedarmonm of t6e warY fo�wluch�his aamu�rs hEsuad 0�.I � ��L' �
(Sec.3W7,Giv.C.�. '
lendei a Npme �
LentJer�q�dms► �
I cartliy Nwt I iwve read�fiu app��caf�on cmd sta�e Miqt ihe � �
above information is carx�.I agree to comply w1�h all G,oumy
ordinancn and S�a�e iews regula��ng Pl�mbing,and hpreby ;
aWhprixp repre»MWivBS Of fhis Counly la enter uppn Ihe .
a6or - nnpna pi P����^W�P�� SEE REVERSE FOR EXPLANATORY LANGUAGE
gntllVre of Per7nilte DGte
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