HomeMy WebLinkAbout1761A ��� � ,
q� WORKERS'COMPENSATIDN DECLARATION �pp�'�q�lp� FOR PE�JNIB!!�� P�P.!!!�!T _�,.j.
� I hereby affirm that I have a certiticale of consent to self ��yJq Pw �
insore, or a certificate of Workers'Compensalion Insurance, CE 817(REY.10181) �
or a certified copy thereof(Sec.3800,�ab.C.) GOUNiY OF LOS ANGELE$ BUlLDING AND SAFETY
*� Pol�cy��S,�.��mpanY Frc.mnnt Tt�riamnj,ty r/
�❑XCertified copy is here6y furnished.. ' �
a ' FOR APPIICANT TO Filt IN(PpINT OR 7YPE} BUItDING � �
- - ' Certified copy'is filed wifh the wunty 6vi(din inspeo- - ADDRE55 (;- -- --- -�
- tian�eb�.g,f$.5 - RCR by• NUMBER FtXTi1RE OR�TEM - CA ��_ IOGALITY , . ..
r
a°1e APP��Sa�r WATERCLOSET ��
NEARfST -
CERiIFICAiE OF Ex€MPTION�ROM WORKERS' BATH ius cRoss sr. 0/Philli s Ranch -
GOMPENSATION tNSURANCE SHOwER ��ER SO th G ll11 r
(Thia sactlun naod naf 6a compbted if ihe work iavolved by MAiI
the pormii is for ona hundrod dollors(f100)or IQcc.� � LAVATORY � ADDRESS
!certify that in the performonce of the work for whith this
permit is issued,I shall nat employ any person in ony monner � SINK CITY TEl
so oa}o become subjed ro the Worked Compensotion Laws. DtSHWASHER �. • �
'• corarancroaR.C.R. P1um�in INc.
Date - App�i[ant C�OTHES WASHER qpDRE55 �
/ 'OTICE TO APPIICANT: If, after making this Certifica�e of SWIMMING POGY RKEPTOR 1 M
{ .emptian, yov sho�ld become subject to the Wqrkers' .
C4TY 7E�Fq,
Compemo�ion provisions of the Eobor Code,you must forth- �,qWN SPRINKLER SYSiEM
wi�h comply with wch provisionz or ihis permit shall 6e STAIE • • ���. �
deemed revoked. WAFERHEAtER E��N�No. �-336428 ��,q� C—�6
tICENSED CONiRACTORS D€CLARATIQN . - ' pIST�Crnq �i�ROCE55[88K
. . .. . . . . . . . . GASSYS�EM.. ... DUTlFlS ._ _ . .. . . ..._.._..
1 hereby affirm that i am titenced utWer pror�sans of Chapfer 4 �� � /� � I
(commencing wd'h Setnon 700p)of Division 3 of the Business OURE750VER � � �� Y. j
; ond Professions Code,and my ticense,is in full force and e$ect 5 PER SYSiEM � �� � '� FFNAL�"� ' � �
; 33642$ . C-36 on� 1�/9��'7 VAEI�lATIpN.. �,
License NumF��i�.,-_��tic.Ctgss� - - -- ----- - - - — - ---— • --- ---- -...... . .. _._, . . .. . . ...� S
.... Q .. . . ... . . .. ... . . . . . . . . . ... -.
� fINAL H�.,'� d g
CoMractor pote BY �Jfs�! � g
❑ � �
I am exempt under Set. y
8.8P.C.for�his reason � � �
Plan check fee — �
----...____. _..--........ ..
. . Dote: . . . . . .. . . _ ...........
...r. .
.. . . ..:. .FLt3MBFVYG PE2hFfT f55UHJG FEE S.- �. .-�j, j('j ...�.... . � : -. . �t d��l.A.�-�-�..� a
s�9����a 1
TOTAL FEE �]! �� # • �5
. .+ •
�r�
..:....:-... . ....:...:... .. .:.::.....:...
Ptan check oppfican� . . � f •�7�1 J�(} . E
SINGLE FAMILY �
HOME OWNER-BUII�ER DECLARATION Name R� - � � �� � •%[ti�j p�
hereby offirm thot I am exempl6om the Contractor's license p�a��12�85 Ma nol ia Ave.� �
` Law for ihe fottowing reason(Secfion 7031.5, 8usines:and � (f�C�i•:$5
Professions Cade): - �iry � Tel.No.
❑ I,us owner of the properry,wilt da the work and the xversi e -rja�0
sirutture is not intended or offered tor wle (Secrion � � �
70d4,Business and Vrofessions Code). �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending ogency for
the performpnte of ihe work for which this permil is iss�ed '
(Sec.3047.Civ.C.). � •
Lender i Nome
�Lender's Addreu �
I certify that I have reod�his applica�ion and state that ihe - � �
above information is cwrect.I agree ta camply wifh all County
ardinances ond Stare taws regulating Plumbing,and hereby �
authoriza representotives of rhis CouNy to enter upon the
above-mentioned pr rfy for inspection purposes.
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