HomeMy WebLinkAbout1747A (448) WORKERS'COMPENSATION�ECLARATION qpp��CATlO[�! FOR PLUMBIIIlG PERMIT �� �
1 hereby affirm that I have a certificate of consenf fo self �bqyy�q
inwre,or o certificale of Workers'Compensation�nsurance, CE B�7(REV.IOi6t�
or a certified copy rhereof(Sec.3800,Lab.C.) COUNTY OF lOS ANGELES BUILOING AND SAFETY
Q�Y4�85321389comPo„y Fremont Indemriity .
Certified copy is hereby furnished. �
� FOR AGPLICP�NTTO FILL IN�PRINT OR TYPE) BUILDING
Certified copy is filed with Ihe county buiIII///���ing inspec- A�ORESS
lion deporfinent � NUMBER FI%TURE OR ITEM � FEE
IOCALITV
d Dote. c I._.�n�AppliSant WATERQ0.5ET NFAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TU9 CR0.4S ST.
5 COMPENSATION INSURANCE SttOWER ��R S011t�l COU11tY COr
(Thia saction noad nM 6a canpt�t�d if ths werk invpfr�d 6y MAIL �
1lw pwmfl is for owo h�ndrwl doflars(Sk00)or ku.) 3 uvnroRv AD�RE55
1 certify that in the performqnce of the work for which�his .
permif is iss�ed,I shall rwt employ any person in any mortner � SINK ctTY TEL
• so oe to become su6ject to the Workers'Compensation Laws. p��yyqSHER ' � '— •
� —` CONTRACTOR R.G..:R. P lumb in , INc. _ . . .
. . . ....._._ ._ - ..- . . _ . . . . _ ... ,. ... .. . ... . .
Oate 4PPIimN ..�... . . �� CLOTHESWASHER AD��� I
�� TICE TO APPLICANF: If, after moking tbis Certifimte o+ _ 12785 Ma nolia Ave. �
mplion, you shou�d become su6jeci b the Workers' SWfMMfNG POOt RECEPIOR
� Compensotion provisions of fhe La6or Code,you must forth- �qyyN SPRINKIER SVSTEM C}tt � r d� T���� " ?
.R ith compYy with such provisions or tkus pemsiE shall be Sfn7E L�C. I
deemed revoked. . WATERHEA7Es „��SE No. 336428 - �,,� C-.36 i
� LICENSED CONFRACTORS DECkARATION ~ .,DISTRICi NO . 8Y . .. �
t hereby affirm tho}V Pm licensed under proviaions Df Chapter 9. . . GAs SYSTfM � � OU7tET5. . . . .. . . �t] . .. -- .... �
� (wmmencing with Section 7000)of Oivision 3 of the 8usiness OUFL€TSOVER T }
and Professionz Code,and my license�s�n full force and effecf. 5 PER SYSTEM „ . ... �.
FlPdAL
. ...., . . ... . .. . ... . . . .. _ ._. __....... . ...... .___..--- .., . ...__ ._..._ DATf. .��` $. ��~. ... .. . _._.� . _,. -ld
VA iDATIC�Nf �
License Number���_L'ra Ctass�.�_ - 1
FINAL n a �
co�vo�ro� RCR �lumbitt 2 pare 6/19/85 sv ��`l`*�"� � '�
F ❑ I am exempt under Sec. �, �
� �
' B.&P.C,for this reason � �Z
Plon check fee
Dale:
� � - - PlUMBING P€RMIT ISSU4NG�EE$ L1 �C -- :
Signoture �,l ` �1 (4.—/fi �
TOTAL FEE � U ., _
�;r • e s n�
- Pk�n check appficant
SINGLE FAMILY I • •l�Pi S O �
HOME OWNER-BUIL�ER DECL4RATION Nnme R.C.R. PLLTMBING, INC.
.reby affirm thot I am exempl from the Contmcrnr's License ��ss Il0 18 Ve.. � .� a r � _
�aw for the following reoson{Section 7Q31.5, B�siness and g � � ' " ��'��" �
Professions Codej: �i�y Tel.N �j,�C�—��
❑ 1,ns owner of the praperty,will do the work orxi the �
structure is not intended or offered for sale (Section �
70d4,Business and Professions CodeJ.
CAh(STRUCTION LEN�iNG AGENCY
1 hereby affirm that there is a construction lending agency for . �
the performance of the work for which this permit is issued .
(Set.3097,Civ,C.).
Lender's Name �
Lender`s Address
1 certiFy that I have read ihis apptimtion and stale thot ihe �
above informa�io�is correct.I ogree�o comply with all Counry
ordinpnces ond State laws regulating Plumbing,and hereby
authorize represenlatives of ihis Counfy fo enter upon the .
obove-mentioned pro ny fo�inspe�tion purposes. -
/' SEE REVERSE FOR EXPLANATORY U►NGUAGE
R.C.R. B�. 1��1��L�i_ b/�9!$5
$�gr+aWre of Permtllee pole �
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