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HomeMy Public PortalAbout10119 GREEN ST_Plumbing__ WORKERS'COMPENSATION DECvLARATI I y APPLICAMN FOR PLUMBING PERMIT yF Ihereby affirm that I have a ceruflcafe qf cons4nt to self 76A667A Injure, or d cerHflcate of Workers' C•ompe tion lhtumnce, CE 817(REV.'10/Ql) or a certlfled copy thgreof (Set. 3800, Lab. C.) `" COUNTY OF LOS ANGELES BUILDING AND SAFETY Pollcy No. Company 01 l Certtfled copy 1s hereby furnished. FOR APPU CAW TO ALL IN('PRINT OR TYPE) BUILDING IO � I R A��! Jr'+ Certified cppy Is filed with the county building Inspec- tion department, NUM8B2 F1xTUR1;OR ITEM � I"Date Appligant 3 WATER QOSEt Ar— NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' Z BATHTUB CROSS ST, B 44' Q Vy/A.) COMPENSATION INSURANCE ` SHOWER ^ OyyNE]R d (This soolon reed not be cornoIeted If the Mork Involved by the permtt Is for one hundred dollars ($100Y or kws.) 3 LAVATORY MAIL ADDRESSI certify that In the performante of the vyork for which this �� a � S permit Is Issued, l shall not employ any Person in any manner SINK to becgme_subtett to the Workers Compensatloq Dt5HWAsa� �y CONTRACTOR :a,, ttllZ-2v a Amlicant CLOTHES WA$1-11ER NOTICE TO APPLICANT: If, after making 4hls fe of ADDRESS � Exemptlon, you should become sublgct to Workers' POOL RECEPTOR Gompensatlon provtslons of the-Labor Code, you must forth- CIT TEL. NO' with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STw deemed revoked. WATER HEATER NO. L7ASS LICENSE[�'CONTRACTORS DECLARATION DISTRICT NO. BY I hereby affirm that Ibm licensed under provhlons of Chapter 9 GAS SYST� OUTLETS � �4 � (commencing with Section 7000) of Dlvhlon 3 of the$uslhess O�TS,0VER and Pnofesolons Code,and my license Is In full force and effect. 5 PER SYSTEM FINAL DATE VALIDATION a License N-umber Llc. Glass pe FI O Contractor Date © I am exempt under Sec. N 8.�LP.C. forthis reason Z. Plan check fee - l Signature 'Date, Rl{1MBING PERMIT ISSUING PEE; TOTAL FEE POW— Ian check applicant /0— SINGLE FAMILY HOW OWNER-BUILM DECLARATION Name � _5 I hereby affirm that I am exempt from the Contractors License Low for the following reason (Sectl6n-7Q31.5, Boln6M and Address 0 (5R��N SProf"Ions Code :) Clty 7"Lr/I�PL � Tel.No.ca owner of the property, will do the work and thesitucture 16 not Intended or 6ffered for sale (Section 7044, Business and Professions Code). CONSTRUCTION:LENDING AGENCY I hereby affirm that thgro Is d construction lending Nancy for the pgrformance of the work for which this permit is Issued (Set. 3097, Civ. CJ. Lenders Namo Lender's Address_ _ 1 certify that I have read this dppllcatlon and state that the V o 0 7 gbovo Irrfgrmaflorl Is correct-I agree to comply with all County CD j.) c;' o CW / ordiggnces and State laves regulating Plumbing, and hereby 1 .' �� o J authorize represbntotrves of this County to egter upon the ob6ve-mentloned property for Inspection s.purposei ?1 o f SEE REVERSE FQR EXPLANATORY LAfiQdJAGf C) ro v l2- 20-Q4- " Signature of P Date A / ,