HomeMy WebLinkAbout1772A (17) � '
WORKER3'COMPENSATION DECLARATION qppLICATION FOR PLUMBING PERMIT � �
I heroby a/firm tFat I hove a carti4ica�e of coman�Yo self �bqpy�q �
insu�e,o�o certifio7fe�Worken'Companso�ion InsurOnce, CE 817(REV.10/Bt) . �
or a carr�fied copy ehmeof(Sx.3800,lob.C.) COUNTY OF LOS ANGELES BUILDING ANDI�AF
Oicr�$��cmAcnv Fremnnt Tnr�pmn].tY . T� �' 3G .
Certified copy i�hereby furniahed. g��
POR APPIICANT TO FILL IN(RtINT OR TVPE) A���`�5
� Certified copy is filed wAh the counfy building inapx- .
fion dapoMment. NUMBER f'x'urz�°R"E^" o `� wcnurr Diamond. Sar
Dafe L/�%Q.rAppL'�om � wATERaoSEr — NEAREST ' .
CERTIFICAIEOFE%EMPTIONFROMWORKERS' BATHTUB � CROSS57; E)O�PYkl�.11 �S Ranch
COMPENSAnON INSURANCE sHowEa °�R SOl1tI1 COtlit.t C'O i
(Thi�rMfon n�ed nof be rnmpletad li fhs sverk inrelwd by �i� ;
the p�rmlf Is for on�hvndr�d dollon{5100)�er I�ss.) � �qyq� qppp� '
I eenify tho�in the perfrnmanca of the work for which lhis ` �K CITv 1E1. � '
permit is issued,I shall nm employ mvy person in arry monner f _
ao m to become subject�o rhe Worken'GompenaoNon taws. p��yyqy�ER � �
" ��"�^�R.C.R. Plumbin INc.
a
Da+e applimnt QOTHFS WASHER � �
N^i�CE�O APPLICANi: if,a4ror makiny�his Cenih�cte ai sw������ � 12 $5 �1 O�.1S Ave.
��\ t }ption, yov shouid betome subje� �o Ihe W�kers' C�n, . � �pp. �
_1 �..,npenmtion pro.�isio�re oS+ha taba Go�e,you musf forth- �qyyN SPRtNKlER SYSIFM ��
wiTh comply with avch prorisiOns p 7hjs permit sholl be n,,,"�,,�. 336428 ��� C-36 �
deemad�qwked. / wAtER HfA7ER � �,
uCErvSEo CONrnacro�.s aGt�+itwnoN wsraia No. orsoc�ssen ev i
i heroby aff�rm tfat i am licensed under prorisiara af Chap�er v cns 5vs�,H alT�s �
(mmmenci�with Section 7000}of Oivision 3 of rhe Business pURfi�S pVER • d ;
o�d Rofessions Coda,and my license is in iyll(orcp.andeffxL 5 FEN 6YS7EM FiNAI �//� �pAnQN 0 :
LicanseNumber��lic.tloss�;�.� FNAL ��,� y/g� � 1
ca�,.«�a RCR Pltmibinep,,, 6/19/$5 . B� �7� � i
O . W :
1 am exempf�nder$ec. �di1 i
Z �
B.BP.C.4or�his reason p�un check fee . $� 7 T,`Z{� ,
pore:
VLUMBING PERMIT ISSUING fEE E D �� • •� �S i
' Sigrwlum .
rorni r�e �J(p.5� 1 • •7 6 5 a �
� Plon ched o pliwnt i
S�NGLE FAMIIY P �,� � i 7 6,,5�� r
Honn�owniFx-eui�e o�nnav Name R. PL1TI�ING, INC.. ;
R
T� , tebY affi.m 11w1 1 am exempt(rom 1he ConhoNw's�lirense p�dress • � 0�2 9�8 Jr i
_ I for the folipwing reason(Sec�ion 7D31.5,8usines�and j
- Profeaions Code): City �el.N �
❑ I,as owner of Ma propMy,will do the work and�he . . .
sn�etyre is rro�inlended rn offered for sole(Sedion ►
7Me,Bus�ness and Profeuions Code).
CONSTRUCTION IENDIWC�AGENCY . �
I heroby cffirm tlqt ihero ia o consh�ctGon leadi�g agency for - ;
rhe performann of�he work fw whieh thia permN is Issued
(Sec.3097,Giv.C.). �'
i
Lender's Npme � '
Lender's Address
I cenify�hal I hore read thia appliwtion ond sinb tFlnt�he ' ,
above informotion is conec�.I agree ro comply with all�ou��y 3
ordinoncas and State laws regulWing�lumb�ng,and bereby ,
outhori:a ropresenla�ives of rhis CoVNy fo anter upon ihe ,
a6ove-meo�ioned prop�ny for inspec�ion purposas.
�� SEE REVERSE FOR EXPLANATORY LANGUAGE �
R.C:R. B �� � :
Sigiwtvre of Perml ee Do�e � � �
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