HomeMy WebLinkAbout1734A WORKERS'COMPENSATION DECIARATION APP�lC�4TlOR� F�R PEU!!lIBIl�G PERR'UT � �
I hereby affirm that 1 have a certificate of consent to self �yaby�q i
insure,or a rertifimte of Workers'C�mpensation Inwrance, CE Bt7(REv.l0/Bl) �,��1L
or a certified copy rhereot(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY T
VolitY�,�,]���ompony Fr�amnnt� Tnrlamriity ��� 1
� Carti4ied copy is heraby fumished. + � ' BUILDING
FOR APPIICANT TO FILL IN�PRINT OR TYPE)
Cer�fi � iled with ih9� tty building inspeo- ADDRESS �
tion�pn��� R�� by. � NUMBER FIXTURE OR 11EM � F� �p���ry niamond. Bar
WA7ER CLOSEf
Da�e App��4a�� ` �sr. 60/Philli s Ranch
CERTIPICAFE OF EXEMPTIOhF FROM WORKERS' BAiH NB
COMPENSATION INSURANCE OWNER
(Tkla wetioe w�d apt 1r cpmplotad if tla wark iwvdrad hy SHOWER .c14L1 rl C.O
tAa{wrmit is For ona hundred doiMn(Z100}or{asi.) WVATORY �i '~ ��� .
ADORESS
!certify thnt In the perfwmcnce of tha work for which this /
permit is issued,1 shn�l not employ any person in any manner / SINK CITY iEl.
so as to became subject to the Workers'Compenwtion Laws. DISkIWASHER •
/ � CONTRACTOR�C.:R. Plumbin INc.
�a�e � �pplicanr / ClO7HE$WASHER � pppRE55
�'hTICE TO APP�ICANT: If, affer making ihis Certifico�e of SWIMMINGPOOERECEP70R �
rptioq you should become subjett to Me Workers' ���
-�_mpenwtion provrsions of tbe lobor Code.�Ya�must forth- - p t ..-. -. Un--- - •. .-...... .
with comply wi4h s�rk1 p�orisions or ihis permil.sholl 6e �WN 5.R!NKLER SYS.EM � T � -
S ATE cL u . .. .,,..,_IIC. 4 . - . �
� . deernedrevoked. " . :' .. : .. . . ._. �' �.. -. -�'� WASERNEATER. .. ..�. �. ... ,�- . .. .'� tiCENSENC.��- 33t1•iZo �� � CLASS C.�Jf}.-._.•..... �._ .:,. j
LICENSED CONiRACTOQS DECLARATION... . .... . . ' .. . . . .. .'.......
,
� DISFRICT Np,� �
..I hereby affirm thnt!am 1`censed under,qrovisions oF Gwpier 9, ' '' G���T� ��' ��OU71ET5 � � ._.� � j - - � � - :
� (commenc+ng wuh. Fq o 04.Diviaon�of.ihe Business.-.. --.-..-OUT�ei50vfR-�-- . .. . .... - - - - - '
_ _ .. .. _- ___...
� and&afessiansEod�e7+a���ense_isirafuti#«c�`qn��faca ..- . S�€R-SYSFEt�t'.- -. .-... � FiNAt �--�� �.�-� ::�.��€
RCR Plumlaing �19 85 . nAre i�'fs��. u ;
� License Num6er - L�c -. .. -.. -
� .... ....... . . . .."': _ ... - ..'_ ___ "" '. . . _... ."""'_'. . ..:._ ..,..._.. '_' fiNA __ "'_ _ " '. .. . .. f
v {4Al
._,.. . .. #_ , _ . .._ _ . . ,.
. . �.
Cont�actor _�_ Dafe _.�� ._...��.. ..:�� ��_� . .. �... � 8Y'" � . .
T 4 I
-. . - - �,-
v ;
❑ _ _ �.. ;
1 om eaempt under Sec _ _ . . _ .. . . .. � .. .. - � ..- _ _ , -..� f
9.&P.C_for.thu r «*•+ _. w ! !.a 4 Ft � '
Plnn check fee.:-.: -''--_ _= __ _ r
. . �ate: '-- � � � .
. . . . . .�..� . _. _ _._--. . __. .....__ PCUNtBING PERMtT ISSJtk�IG FEE S_ _ � _. _ __ ..� _ . ,
.�..Signature . . " "- -�.. . . 6 c�, k
. . . _ ._._. .'.... .. _�._._ .... �� - ._.� �. .. _,_�_ . ..,_ �'.�. 5 -_ _ ` "_._�' �
- -� - ---- ---- - --�- --- -- -- -- _..,- �----- `- --- --TOTAL FEE � - --- - - _-__-. _. _ _
- - - - --- -_.-._- _._._ . _ _ ..._ u_-.__. . _ ..,_ _ . . _ ...
. .. Pl�n check app4icant s . e�;}��;r:_ s�
- SINGLE FAMILY � �
HOME OWNER-BUILDER DECLARATION Name ��,2 r/-�}� �
re6y affirm tnai 1 am exempt fwm the Contrac�or's License
� i for the foftowing reason(Section 7D31.5, Busines:and 'b'd����27$r3 �$ nolia Ave. � -
Rofessions Code): Cify Tel.No. - �
❑ �,as owner of the proper�y,will do the work and the Riversi e 5�7�5�0 0 �
strudure is not infended or offered for sale(Sedian - �
7044,Business ond Prafessions Code). �
CONSTRUCiION LENDING AGENCY
I hereby affirm ihat thare is a construction lendi�g agency for
ihe performance of fhe work for which this permit is issued
' {Sec.3097,Clv.C.). -
�
lender's Name �
Lendeis Addreu
I certify that 1 have read this appliwtion and state that ihe � '
abova informafion is correct.I agree to tomply with oll Co�nty
ordinances and S�ale lows reg�lating Plumbing,and hereby � �
outhorize representatives of this County to eMer upon the -
b a enli gd rope�fy€or inspettion pvrposes.
�•�•�• �y��� , . �19�85 SEE REYERSE FOR EXPLANATORY IANGUAGE
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