HomeMy WebLinkAbout1416A (7) WORKERr�oM�NSAT�oNOK�,RAT�oN - APPLICATION FOR PLUMBING PERMIT � ;
I fiere6y aNi�m that I hare a cenifimte of consen�w self �y,qyy7p
insure,or o cenifica�e of Worken'Compenwtion Ineuronca, CF an(REv.iai8i) � �
or a cerlified copy thereaf(Sec.380p,lqb.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY •
a11047 ComPooy Fireman�s Fnnd
ce�r�fied�opy is tierc6y fu.��stied. 296/83S/Lot 1 �
� IOR APPLIUN7 TO HLL IN(PRINT OR TVPE) BUI � ,
Cert�fied copy ie filed w��h Ihe counry building inspec- �R63 elfield Drive i
tion depaMmenl. NUMBER wxruxe oa irenn � F� � iocnun gowland Hei hta � !
/ ��_ WATER CLOSET
Date 8/f��fS3 qppliSon�R[:R h ��1Cl.dsual� 3 Ra
CERTIfICATE OF EXEMPTION FROM WORKE� BATHTUB CROS$ST.CO],LID$ fi grg�g�enW Dr�� . � +
COMPENSATION INSURANCE OWh7ER j
(Thls secflon n�ad nof bs comp��t�d IF ihs werk Invelred 6y �A OO - j
the p�rmll ls for ons hvndrad do116n(5100)or 1���.) �qyqtptty � wp�4600 Campus�Dr. �
I certily dwr io Me performance of Poe wak fer which rhia
permit is iss�ed,1 shall not employ vny peraon in ony monner � - Q'a �� N ort Seach '�`�"O�540-0500 �
eo m�o become s�bjeci to rha Wwken'ComperqaKon Lows. DISHwaSMER . . {
� CO^�ACTOaR.C.R. Plumbin Inc. ;
DCIe spplicpnt .- C10THF5 WASMER � �� �
NOTICE TO APRIG4NT: If, after making�his Cenifitdte of j
� �p��on, you ahould bemme subjed ro tha Wo�ken' S�nM^^i^�Gvoo�REC�pipR j
ipe�aa�ion provisiom of the Labor Cadq,you must fonh- �,qyyp�gp�q.�K�Ea SrSTEnt ��n Riverside ' T�`�NO� 71-5000 i
�J�uh tomply with sueh provisiorn or thia permit sMll be 7
daemed ravoked. WA�t�n� i�i��r.�o336428 � -36 �
ll(�N$E�QONTRACTORS t�(1ARATION � qSiR K T�l O. PftOCR BY '•
. �here6y uffon.ew��am licem�urEler arcv�sions of pwp+e.e cas srsiFAn amei5 �p —� '
�cOmmencing v�tith Settipn 7000)of D'rrision 3 of Ihe Business pUf[t7SpyER �� �' i
and Profeuio�Code,and my licenae is in fyll faceand effea. 5�En SYSiEnn `� � FINAL 6 �
DAh VALIDATION � �
license Numbn 336428 i��.C�s C-36 '�
ac
FINAL Q ;
co��rono�CR Plambin� o,�e 8L4/83 ev � ,
� I om ezemp�under$ec.� pW, {
� i
B.6P.C.for this reawn � 2 j
Plan Shetk fee �
Date: PIUMBING PERMIT ISSUWG fEE S Q � �% ��1! �,h r! '
� $ignaN+e �i
TOTILL FEE /� � :;• • • •.•)
SINGLE fAMIIV - � . Plan check opplrcanl - y
C � ��� �lJ ?
HOME OWNER�UIIDER OECLARATION Name� R.C.R. PLQMBING INC. , c ; - - �
''vreby off'nm�ha�I am eaempr 6om rhe Connqc�or's Liceroe `^'1�n" ;
�:o:ths`-!:"�::.-.g reasan{Saci'.on RU7.5, Bostnuas o��u ndd.��I2785 Ma o2ia Ave! . . . . r _p_ � :
'�"S'°":cod°�: nti Ftiverside T��.N�.371-5000 n 2( ��� i
❑ 1,as owner of the propeAy,will do the wwk a�tha �
sfructurc is no1 intended or offered fw eole�Section . . , �
7044,Businns and Proless�ona Coda). � ,
CONSTRUCTION LENDING AGENCV ' �
I hereby offiim�hat�hera is a conshuc�ion lending agency for
ihe performance of iha work for which ihis permi�is iasued
(Sec 3097.Civ.C.). ... . . ,
J
,
Lende�'s Name
Leoder'a Address _ � �
I certify tbot I have reod thia opplimtion ond sro�e�tho�the , . ,
above informaiion is correct I ogree�o comply with all Couary ' - - �
ordinances and S�ate lows regulating Plum6ing,and hereby �
au�haize reprmentatives of rhis County to enter upo�t�e � � � �
above-menlioned properry for inspec�ion purposes.
�,,I SEE REVERSE FOR EXPLANATORY IANGUAGE
RCR by://U�.� 8/4/83 ,
S�gnoture of Vermit�e pate
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