HomeMy WebLinkAbout1687A (17) woR��'�^^�N�T�����,�,T�°N APPLICATION FOR PLUMBING PERMIT � �'
I he.eby affirm rhai I hove o cenif�cara of comenr ro self iy��p , � ,'
insuro,o�a cerr�ficata of Worke�i Compensa�ion inwronee, [E ev(REV.�0�81) �
w o cenified eopy�heroof(9ec.380Q 1a6.C.) CQUNTY OF LOS ANGELES BUILDING AND SAFETY . . .
� P�ol'Ky No.---.F—�PaM . . . • � ,
CeHiffed copy is heroby furnished. e�p�� f
� � Certified copy is flled with the munN Eu�iding inspec- �oR arruciwt ro riu tta�vmrtt dt rv�) d��� /a � / ��� �Q .
� lion d9pG1MEn/. NUMBEA Fl���� � � LOGLITV ���� �� .
WAfER Q�ET �
DOM -- Appli}vnl fJFARE57 ,
� � CERTIF1CAiE OF EXEMPTION FitOM WORKERY enn�tue Ck055 Si.
. � �� COMPENSATiONINSURANCE - S�� a'vNER R06 �+�/ �
' (Thh s�efion nNd net-6�eerhplsT�d ff fkrwbrk Inrolvod br _ . ,yNh - ,
th�p�rmlt N ier oR�hvndnd d0110ro(f1U0)ur I�sa.) �Uyw�r p d ,qppRESS �
1 cenify�hm in the perfwmaMe ot the+work fa wRich�his L � . '
, permis is issned,I stwll�otemploy any petaonin om�mcnnes �7� S ��'n' O d � ' �'�� �
so m�o baco�ne subjed ro�he 4�Vakers'COmpensation lovrs. �p�yyqSHER � '
w coriruaoR /�/il.Q/1 G/.g+� �Rw�y�3
Oote a"�'�pplicaN M?N CLOiNRWASMER aoort�ss /¢�MO '���
NOTICE TO RPRlCAIVT: If, aHer maki �hia Gmtiftmte of ������Q . � f ;
Exempt�on, yo� skovld betome wbjed ro �he Worken' �iTy � hi,p�p. �,
{�ompenwiio�provisipna of the 4abM�Cpda,y0y musl}onh- LAWN SAtINKIER 5�'STfM L3's' 3 �
wHfi mmply rtitfi wch prwitiqm a fbia pO/mii 4ho11 ba .n`�E�. „a U�C� n � i
deemedrevoked. WR7ERNEATER Q �
U�ENSW CONTRliCfO.RS QE.CxARATIfaN ���T�. �� i
Il�erot�yoffirm�that/amlicensedundqrprro�isionsof�Choptm9 �'�� �� �. $ � rp �
(commendng with Soc�ion 7D00)04 Piv,ision 3 04 It�e Susiness- OIfRErSovE Y '
y ,
and Profess�vn>Cvde.an�f my licanse p��fo�f foree.er�eff�• s v�R tmAt VALIbATION O �
. � oA,� a a � � �
-lr�a ,� ,
License Number �- �7�L �ic.C7qu � �
� � �- S �M Or✓ . �fINAL O !
Crnnrucror��✓A+�4AiN9dn��e �•/�'g BY (�y�,_,� W �
❑ 1 am exemp�under Sec. . - ydi i
a.3v.t.Fw rhn�eew� plon check fee � Z �
�O�a: PlUM81NG PERMIT ISSUING FfE: � �
s�y�wro.e s.�arQ,...T -_ D D !
TpTALfEE
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SINGtE fAMIIY %°�`h°`k°Pp�"�`� . f 1 6 8.7 A
NpME pVJNFR-8UIIDER DECN4RATION Name . . . .
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I hero6y affirm thm I am exempt from the ConMactor'a licenae �� ���� �5 t
Low for the foHvwinp reCnon(Senitm 7fK��.S.9�siness and ��
Professiom Code): �ity . � Tel.No. I • �5 8 5 0
❑ I,aa owner of�he property,will do�he work ond�he � . • • •5 Q�p�
shucNre ia not intended or oHered for sale(Sec�ion � �
704t,Bv�iness ond Profen'rons Codel. � O 2 2 2—a�4
fANSTRUCTION IfNDWG AGENCV . �� � � �
I hereby oHirm ihaf there ia o consn�ion lending agency Ior �
the performance of rhe wak for which thia pe�mif is issued
(Sec.3097.Civ.C.). ' i
lender's Name "
Lender_'s A�dreu �
Ad
I certify rAat I have reed�his applimrion and ata+e rhat fhe . � ,
abore informa�ion ie cortect.I ogree ro comply wiih all Covnry . .
ord�nance�and State Ivws regutaei�Pl�mb�r+g.and hereby
outhwize represenwtivee af rhis County to en�e�upon the � �
aboveanentioned propeny fa��+speceon purpo�es. SEE REVERSE FOR EXPLANATORY LANGUAGE �
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