HomeMy WebLinkAbout1732A WORKERS'COMP�NSATION DECLARATION APPLIGATIO(V FOR PlUM�1(V� P�RlVtlT ,p � I
I hereby affi�m ihot I hoJe a certifiwte of mnsent to self �ypyi7A ` _.f�pZ
insure,or a certificate of�Worke�s'Compensotion Insurance, CE 817{REV.10/81) 0^�'(D
o�a certi+ied cop thereof(Sec 3800,Lab.G} COUNiY OF l05 ANGElES BUILDING AND SAFETY
. Poi.�Y�P853�Z38�ompo�Y Fremont Indemitity � �
� � Certified copy is hereby fumished. ..
� . � FOR APPLICANT TO FtLL lN(PRINT OR TYPE� BUIl01NG �
C�e�fjedAopy:iqfiled with thwypl{nt%bslding inspac- �irv' .
de¢d�tn�e�+ t<<.tt � NUMBER Ff1CTUREORITEM � FEE
Dpte p,pp�i4nnt �,3 WATERCLOSET ^ NEAREST
CERTlFICATE OF EXEMPTION FROM WORRERS' 02 �tHTUB cRosssr. 60/Philli s Ranch
COMPENSATIQN INSURANCE SHOWER ��R South Coun r
(Th1s sae4Wn no�d ao�b�eumplQt�d if eho work Irtroiwd hy ���
ilw parmit k Fw ono kundrad doUars(j100)or bas.) 3 iqvATORY . qpp��
4 certify thot in the performonce of the work for which Ih4s
permit is issued,I sholl not employ any perwn in any manner SINK CITY. TEL N .
sa as to bemme su6ject to the Workers'Compensotion Laws. DISNWASHER •
cor,�rRacroRR.C.R. P1L�in INc. fff
Date - Applicanf CLOTHES WASHER ADDRESS �
�e'7iICE TO APPLICANT: If, after making this Certifica�e of �.2 �S Il 1�
mption, you shooid beoome subjad �o �he Workers'
SWlMMING POOI RECEPTOR
C1TY . . TEL f�,
� mpenwfion provisions o/the Lobor Code,you musf forfh- lqWNSPRINKtER5Y5TEM � �
with compty with wch provisions or this permi! shall 4e S7ATE IIC.
deemedrevoked. i WATERHEATER (� ,� ���EN�r�o. 336428 aass C-36 i
LICENSEO CONTRACTORS DECLARATION o�Ste�C7 aROCESSED BY i
I hereby affirm)hat t om licensed under provisions of Chaptar 9 GAS SYS7EM OURETS J� I
(commencing with$echon 7000)af�rvision 3 of the 8usiness OUriET50VER � d �
ond P,ofessions Code��$r�y�i8ense is in futl forcG,ancyeffecf. 5 PER SYSTEnn fDI�N� `�/fl�,y- � VA DATION V `
I+ Jb �
titenae Nu�a Lic.Gass - p� �
R PZumbing 6/19/85 . avA`�2� � �
co�,.o«a oate �,
� I am exempt undar Sec. � �
B.dP.C.for lhis reason �
Plan check fee �
. .. Date: . . . . . .... . . . . . .. ._.... .
PlUM81NG PERMIT ISSUfNG FEE$ � (� �
Signature �i rr'�,�F. �
.. ., : . ... TOTAL FEE ��U . . ,.... �:r• ..!..s w....
` - - Plan check applimnt � • •&�5 C �
SINGIE FAMILY INC.
MOME OWNER-BUILDER DECLARATION Nome r T
•reby affirm that I am exempt from the Contractor's License � ° °�F��J��� '
� .v for ihe{ollowing reason(Sectian 703T.5, Business and ��0� � �' �
j Professions Cade): Cii�, � Ta� Q t'.C y"�S
a �
1,as owner of the property,will do the work and the
structure is not intended or offarad for sale (Section � i
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY , �
I hereby aifirm fhat there is o tonstruction lending agency for �
ihe performance of ibe work for which lhis permit is issued � i
(Sec.3097.Civ.C.). i
I
Lender's Name I
' � Lender's Address �
I certify�hat I have read this application and state that the �
above information is carrect.�agree to tamply with all Counry
ordinances and S�are lows regulating Plumbing,and hereby
authorize represen�atives of this County fo enter upon the '
above-mentioned operty for in ection purposes. SEE REVERSE FOR EXPLANATORV LANGUAGE
R.C.R. $y� A� �(�1q,f$o
Signoture of Permittee Do e �
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