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HomeMy WebLinkAbout1158A (5) WORKERS'COMPENSATION DECLARATION I APPLICATIO{V �OR PLUMgIR�G PE�tT ���777 I hereby affirm thof i hcve a certificate vf consenf ro self 20-OD26 DPW 6/87 G,� I i�sure,or a certifitote of Wwkeri Compensalion Ins�rance, 76Afi87A - I I � or o certified copy thereof�Sec.3800,�ab.C.) COUNFY OF LOS ANGELES DEPT.OF PUBLIC WORKS U P❑olity No. Company Certified copy is heraby furnished. f OFOR AP7LICANT TO FILL IN PRINT OR TYPE g�����' Cerfified copy is filed with the counry building inspeo- ( � A�DRESS � 3 3 �+�'� �S`�G��+V� tiondepariment. NUMBER FtXTUREORITFM � FEE ���'�, . � ��, ��� ✓ � WATER CLOSET Date Appfi4Ont NEAREST � CERTIFICATE OF EXEMPF�ON FROM WORKERS' BATH TU8 eRoss sr. �—t.YY�p- � COMPENSATIpN INSURANCE OWNER /� A [ (Thi�wction nwd no►Fw compbt�d if 1h�work imolrw!by SHowER ( '�D t 4� �(f��L�i C S t� � � tb�pormk�s(or o�w hundrod dollan(SI00)ar Irss.) �qyqTagy M'°'�� c � A��RFSS l' �. I certify that in the pe�fo�monce of the work for which this t permif is issued,1 shafl nof employ any person in any manner SINK f�TY .�_ hY� TEL. -�� ��3 � w aa ro bacome w6ject to tht Workers'Compansotion Laws. DISHWASHER CONTRACTOR � a�� � .�� 4 1°l��� ,��� � Date pplitant��,��ti�'� CIOTHES WASHER ADDRESS NOTI O PPIICAkT: If, offer making thia Certificate of C u Exemp4ion, you 4hould become subjeU to the Workers' SWunMING POOI RECEVTOR ` > � Compenaclian provision�of ihe lobo�Code,you myst fonh- IqWNSPRINKtERSYSTEM C'TY �� � t2 �` # with comply wifh euch provisions or fhie pe.mit aha�I be STaTE LIC. deemed�evoked. WATER HEATER tICENSE NO. ` �� �- ` �b I LICENSED CONTRACTORS DECLARATION D�STRIC/NO. ` 55ED BY 1 hereby affirm that I am Ilceroed undm provislans of Chapter 9 GAS SYSTEM EHl7LET5 ; (commencfng with Sec�ion 7000)of Divi�ion 3 of�he Buaineas OUTtEi50veR rit`G.-�'t'!�' z and Pr��ssions Cods,and m liceme is in full fores and effect. S PER SYST r- 3= " yy�'�7 �_� � � oaTE t0 ��� � S VALIDATION U ± Uwnw Number �ic Claaa �` �/' FINAI � � Contractor ���- /�l�'��Octe � �' �' BY �1-- ❑ f om sx�mpt und�r S�c. V i a ; B.BP.C.for�hl�reason_ S�.. p�on check 4ee �� � 5 8(1 . Z , Da�e: �' � �� PIUMBING PERMIT ISSUING fEE$ � #r•• • �5 ' $i�noture � FOTAL FEE I+�:I 6 5 Q � Plan check opplicanf • • •� Q 5 n'W ' S�NGLE FAMILY HOME OWNER-BUILDER DECWRATION Nome Q���—8 9 � 1 hareby affirm that 1 am exemp�from the Contrecror's L�cense qddress � � ' law for the following reason�Seclion 7031.5, Business and � Professians CodeJ: City Tel.No. ❑ 1,os ownat of the p�operty,will do the work and the � structure is not intended or offered for sale(Section � 7044,Business and Professions Code). # CONSTRUCTION LEND�NG AGENCY � I hereby offirm thnt Ihere is a construdion lending ogenty for � the performpnce of the wark for which this permir is issved j (Sec 3097,Civ.C.). � tender's Name - Lender's Address ' I tertify that 1 have reod this opplica�ion ond stala ihat the � � above information is conect.I agree to comply with all County ordinonces end Slote laws regulating Plumbi�g,ond here6y � _ authorize representatives of this CooNy �o enier upon ihe � above-menlioned property for insp tion purposes. � __�� �/�/�� � SEE REVERSE FOk EXPLANATORY LAMGUAGE ? /�� �; SignaWre of Permiuee } are � � zi � � � � i; ; ':� o ��;., •.� � 1 ' � _ ,- :` G �- a; L: v 4A'O t: O y, p C C z � ` , .• v. 4 �. ; Q,y; r; O G O L . 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