HomeMy WebLinkAbout1775A (446) WORKERS'COMPENSAT40N�ECLARATION �PP�l��T10� ��F ����B��� p�o�lT � I
I hereby affirm that 1 bove a certifimte of consenf to self �yqy��q
insure,or a certifimte of Workers'Compensotion Insurance, CE B17(REV.10/81y ��� i
or a certified copy fhereof(Sec.3800,Fab.C.j I
COUNTY pF lQ5 ANGELES BUILDING AND SAFETY
' Ot�yT►1�R4491 RR�ompony Fremont�ndemnity . �-
Cenified copy is hereby furnished. .
- FpR APPUG4N7 TO FILL IN(PRINT OR TY�E) BUILDING q� �
' � Cer�ified copy is filed with fhe couMy bui ding inspec- AODRESS oC
tion deportment. Nt1MBER FI%TURE OR ITEM @ FEE ����F� Dk�ond Bar �
� Date �����_Appli4ant WATERCLQSET � NEAREST
�� CERTIFIG4TE OF EXEMPTION PROM WORKERS' BATHFUB a � �Rou ST, 60/Philligs Ranch
��� COMPEPf5AT10N INSURANCE OWNEK
� (Fhb sactbn naad�roT Iw complotad t1 tIN work Fn�.ofwd by sHowea S OLlt21 �.'Ol1ILtY �.'Or
Ibe permtt is for ana hundtod do�bu(SIOOy ar less.) LAVATORY �'��
oJL ADDRE55
,�� i certify that in the performance of tMe work for which this `
permit is iuued,1 shQll nof employ any person in any monner SINK CITY 7E�,
so as to become subjecr fo rhe Workers Compensation laws. •
��� oisnwasr+eR
�k � CONTRACTORR.C:R. Plvmbin , INc.
�� Da�e epplicont CLOTHES WASHER A��� �
' NOTICE TO APPLICANT: If, after making ihis Cerlificate of 12785� Ma nolia Ave.
Exemptian, yoo should become subjec� to fhe Workers �{ SWIMMINGPOOtkfCEPTOR
�� Compensation provisions of the Labor Code,yau mast forth- CkTY R•V T ��"�'
'� wilh comp4y witb such provisions or Ihis permit shol) be �WNSPRINKLERSYSTEM STAh • -
deemedrevoked. � WATERHEATER ' < <,��No. 336428 nA� C-36
(fCENSED CONTRACTORS�ECLARA71pN DiSTRICT NO., � pppCE55FD gy j
l here6y o#firm thot l am lirenge.d under provisians of Chapter 9 GAS SYSTEM OUttETS . ___ . _ �� . _ _ . _ �
�' (commencing with Section 7000j of Oivision 3 of the Business OURET504ER � Y �
and Professions Code,and my�icense is in full force vnd affect. 5 PER SYSiEM ' 3
.. . ... _ . . � . .. .. ...... � .. ..... ......_. .. .. . .. .... .. _ . _ ._ ..�.. �. .. ._ _.. aJ
o,a�� 1.Z�3� �- VALiDAT10N �
License Number_3�,(��.�_Cic.Class�,,,��_ � � i
Confrocror
RCR Pluml�ittgoo�e 6/19/85 . sv''��y�/ a �
v �
a .-- �
' I am exempt under Sec.
B.BP.C.Fu fhis reason � � � � �_ �
Plan check fee �1 7 7.5 P:
� Ov�e: . _ : . � ' . . .. ...i, , ... � _ . N�• • a a �� � �
. - .. - ALUMBlNG PERM4F ISSUING FEE$ - ��.1,✓�i - . ... - . . �- . e
Signofore
� TOTAL FEE �l/_ (f--�y �'' �7�5 O
!tv J </
Plan check appficant • • •(6 rj��;
SINGLE FAMILY
_ HOME OWNER-BWL�ER DECLARATION Name r ' �'f.2 9 v,8 v
-I hereby affirm that f am exempt frmn the Controcyor's litensE �, ��5 � . . .. . . ,
law for the fol�owing reoson(Secfion 7037.5, Business ond � �� � � � � �
afessions Code): �iry Tel.N _ �
�,as owner of the p�operty,will do the work and ihe
stroct�re is not inlended or offered for mle(Section �
7D44,Busineu and Professions Code). ' � �
- CONSTRUCTIONIENDWGAGENCY
�t hereby affirm that there is a mnsirudion lending agency for
the performance of ihe work for which this permit is isaued
�(Sec 3047,Gv.C). .
't Lender's Name
Lender's Address �
I cerfify tha�I have read this opplication nnd state�hat the ,
above information is correcL 1 agree to mmply wi�h all Counly
ordinartces and Sfale laws regulating Plumbing,and hereby
aufhorize representalives of fhis Coonty to enter opon the .
above-mentioned pro rry for inspection purposes. �E REVERSE FQR EXPLANATORV LANGUAGE
� R.C.R. BS1. Q�IU.►t,,�j 6�19�85
Signaiwe of Permittee DWe - I
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