HomeMy WebLinkAbout1749A (446) WORKERS'COMPENSATION DECLARATION �ppi����5�� �OF P!lJMB!!lt�s PEP.!l��T �� � I
I hereby affirm fhat I hove a certifimle of mnsent to self 7eA667a �
insure,or a certificote of Workeri Compensption Insumnte, C€817(REV.IOi81) �
ar o certified copy Ihereof(Se[.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
a���35"�71�89Com�a„yFremant Tnd mn�ty �
Certified copy is hereby furnished. .
� 60R APPIICANT TO FILL W(PRINT OR FYPE) BUIIDING
Certified copy is filed with ihe county buil ing inspec- A�ORESS
tion deparlmenf. _ NUMBER FI%TURE OR ITEM � FEE
� � LOCALITY ,
�pte �/l 9/R S p ��p�� WATER CLOSEf NEAREST
�R_ Pp 4 � ` cRosssT. 60/Philli s Ranch
CERTfFfCATE OF EXEMPTION FROM WORKERS' BA7H TUB
COMPENSATlON INSURANC€ SHOWER OWNER South Countr C
(This sactior naad wot be compiotad if tFw work fnvolvod by �i
iho p�emFf is ior ona bundrod dollon(5100}ar law.) tqyq7pRy � "' A�DRESS
!certify thai in ihe perfwmance of�he work for which this
permif ig issued,i ahnll not employ ony person in¢oy monner SINK (p CIFY � TEL.N .
� so os to become subject fo the Workeis'Compensation laws. � ptSHWASHER � •
CONTRACTOR��G'��_ pl�hin INc.
Date Applicant CIAiHESWASHER
N^iICE TO APPLIG4NT: If, ofter moking this Cartificate of a�� 1278 � Ma 11 l.�lc1.
� y�( �ption, you s�rovfd 68comE SuEjEtY f6 fRe Workel3' � SYVIMMtNG POOI RECEPFOR �F� , _ � �
���b_.�rpertsateon provisions of the Eabor Code,you must torth- �� � � - ' ' � �'
� wilh comply with such provisions or ihis permit slwll be �H'N SPRMKLER SYS7EM —
deemedrevoked. WATERHEATER �c�T�;seNo. 336428 clnss C=36
f LICENSED CONTRACTORS DECLARATIQN ' �
- - - - .,_ . . ._. .---- � _._
_-_ QISTAtCE NO. - -PIiUCFS5ER9Y-_
'_
k J berehy 4ffirm lhat 1 a�R(iCensed under '' p -_ GAS SYSTEM_ .. _ ___. _ _..�.,,.._ _ _______. _ _t _ '_ _, __ __ _ . . __ �
prPvaStonSo�-G'+a ter9`- -.. ... . . --���-.-- :- , . � .�..
(commeacing with Section 7000j of�ivision 3 of the Business OUTtEi50VER � �� Y
and Profassio�s Code,and my ficense is in full fwce and eHect. � 5 PER SYStEM FINAI �j �
DATE• I�,6 f S°�.. V IDATiON .. . y �
I.i[ense Number�tic.CIa55��_ - - �
�
Fi1VA1.
Controctor_RCR PZUITlt7j.Tigno�e6129185 sr � � �
� � . �,..
I am exempt onder Sec. � �
� �
8.8P.C.for fhis reason . ... � . . . � f
Plan theck fee ��7 4 Q R �
Dafe: PtUMBIhFG PERMtT t55U4NG FEE$ Q jJ (
Signature
- - � - --- . . TOTAL FEE �! (� . . . . . . �f• ����S. . �
. . . . �� - � .. � � � � Plan check�applicant --� . - . � . . . . � j 6 •�$�(�' �
SINGIF FAMIIY �
HOME OWNER-BUILOER DECIARATION Name • � INC. �• •$�5[�'c�s
' Ih1 -eby affirm thar t om exempt from the Connactor's liceate � ��Bu • e. . � � � �� '0�2 9�$�J '� �
�iS ,far'thg foYlowing Yeason(Seclion 703T.5,8usinese ond I
Profess�ons Cade�: City Tel.N
❑ I,as owner of the property,will do the work and the � �
strutture is not intended or offered for sale (SeUion
7044,Business ond Professions Code). '
CONSTRUC�ION LENDWG AGENCY
1 hereby affirm ihat there is a construction lending agency for � �� �
the performance of the work for which this permit is issued
(Sec.3097,Civ.C.).
Le�der's Nome �
Lender's Address
1 certify that I have reod this applicalion and srote that the � .
above information is correct.1 agree to wmply with ail County
ordinances and Stole laws regulating Pfumbing,and hereby
authorize representatives of this County to enter upon ihe
obove-mantioned roper�y for i pection purposes.
���� SEE REVERSE FOR EXPIANATORY LANGUAGE
�Ii.C.R. Bv_ � F�79���
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