HomeMy WebLinkAbout1746A WORKERS`COMPENSATIONDECLARATION APPLtCAT10N FOR PLUMBIRlG PERMIT �� �
�I bereby affirm that i have a certifiwte of consenf fo self �ypyy�q
insure,or a certificoie of Workers'Compensotion Insuronce, CE 8II(REV.70/BI} S,Z
or a certified copy thereof(Sec.3B00,Lab.C.) COUNTY OF LOS ANGELES BUIIDING AND SAPETY
�Po�icy(�StSZo�R��ompany �'romnnt Tnr�omri��
�I❑ Cerrif'red topy ishere6y furnished. , gUiIOING
fOR APPI.ICANT TO FILL IN(PRINT at TVPE) qppRESS .�
i4� Certified copy is filed with the county 6u' ing inspeo- �
� fion department. NUMBER FIXTUREORITEM Q$ FEE `���TY
WATER CLOSET
Date � /�TAppli4o�t � ` NEAREST
� CERTfFICATE OF EXEMPTION fROM WORKERS' BAiH 7U8 CRO55 5T.
'� COMPENSATION fP15URANCE OWNER
-�(This soction nwd�rof 6v compiabd iE�h�work in�olv�d 6� SHOWER
�I 1ho parm�t Is for one hundoad dotlors[SI00)or lass.) 3 LAVAIORV ���
ADDRE55
'f certify thot in the performonce of the work for which ihis -
�permit iz isaued,1 sholl not emptoy ony person in ony monner � SINK CI7Y lEL
�so as to betome subjecl to ihe Workers"Compensation Laws. DISHWASHER
CONTRACTOR
�ate �+pplimnt ( CLOTHES WASHER ' ' ' • � '
ADDRE55
� `TICE TO APPLICANT: If, after moking this Certificate of 12785- Ma nolia Ave.
mp�ion, you should become s�b�ed ro rhe Workers' d SWiMMING POOt RECEPIOR w
C.ompensotion provisions of the la6or Code,you musf fotth- lAWNSPRINKlER5Y5TEM ��TY � � iFi NO � e
wHh comply with such provisians or ihis permit shall be STnTE 336428 "`� C-36 '
deemed revoked. wATER HEATER UCENSE NO. CUSS �
ItCFNSE�CONTRACTORS DECLARATfON DiSTRtCTN�� PROCESSEU Bv �
1 heraby offirtn Nwf i am kicense�urtder provisinns of ChopFe�4 GAS SY51EM OUTlETS / •
(commenCing wilh Section 700Qj of�ivision 3 of fhe Business OUTtEFS OVER 6 . � �
and P�afessions Code,a�d my ficense is in full force and effecL 5 PER SVSTEM F�u�� / / _ S
"_ . . . . .... .. . . . . . DATE - `x/�I 9"S. . .. ALiDATi01�f � I
: License Number��_����Cfass_�_,�� ���C � � �
. . . ., _..._. . - . . .. ..,.,
r
. _ _ . . . . ..... . .. . �
Contractor � .� p�71T1tS'1�T3?�Dote Fi��.�$r� . BY ���� . _. .- - -. , - ,.�3 i
❑ I am exempt under Sec. , � �
fA �
B.BP.C.tor this reason ptan check fee � �
. <� %ii.��!
Date: PLUM8ING PERMIT FSSUING FEE$ 5'n t
Signofu�e �' {�• • a;• •� �
- . TOTALFEE �'� d
! •'Q��:fJ�
Plon check applicont
SWGLE FAMItY - ��e •�S�5(�?� i
HOME�WNER-BUILDER DECtARAT10N Name
•� ��eby otfirm that I am exempt from the CoNrador's L�cansa A��S . _ , , .� U?,G�j'.—�w ,. I
�ww for tbe following reason(Section 7037.5,Business and 12�785� Ma nolia Ave. - -
Professions Code): City � Tel.No.
❑ !,as owner vf the property,will do the work and Ihe zversi e 7 -5 0 .
structure ic not intended or offered for wle{Sedion � �
7W4,Business and Profetsions Code).
WNSTRUCTION LENDING AGENCY .
r��I here6y affirm that there is a cormtruction lending agency fo�
i„��he performance of the wock for which this permit is issued �
�_(Se[.3097,Civ.C.).
Lender's Name
Lertde_r's Address m � - .
I certify thot I have read this application and state that 1ha �
above information is correci.I agree to comply with oll Counly
ordinances nnd State laws regu�ating Plumbing,and here6y .
ourhorize�epresenlatives of this County to enter upan Ihe . '
above-meNioned pro rty for inspeclion purposes.
n SEE REVERSE FOR EICPLANATORY LANGUAGE
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