HomeMy WebLinkAbout1129A (5) �"'°RK�s�°""�"�"°"°�a�"°" APPLICATION FOR PLUMBING PERMIT �
! hereby affirm thpt I hpve o cer�lfica�e�o4 consen�b self `
insure,o�o certiffcate of Workers Compensotion Insvrvnco, �F�(REV,10i81) . L�~
or� r�i +heroqt(sec.3s0p,tab.C.) COUNTY OP[OS ANGELES BUILbtNG/iND SAFETY !
vor�r�-'}—�q`��w�--0�°��3NR1ro�lcw�o�.mu re+�►�.-
� Certified wpy ia heroby fureished. -
� fOR APPLICANT YO FILL IN(PRINT OR iYPE) &IIIDtNG
Cen�fied copy is filed wlth rhe covnry buildi�g inspac- ADORESS G �
�ion departmenf. WUM9ER Flxit1REORrtEnA � - � iEE .���n, .
j���y� WAiER CLOSfT
/� _ 9
Oatv g���Sff�=��� APPI.14on��sAo+p*�E.� , oo �CKO$5 St. . .. '.
CERTff1CAiE OF E7�MP'f10N. N4 WORRERS' BAM NB . . . ... �
COMPENSATION IN NCE sMOwER �Ep ARIAI �
(Th�s sastton naad not 6s compfNad fF Yht wedc lnve�wd by ;
tha p.rm�r 1.For on•hdndr.d dollers(St00)er 1•u.) UVwTDRr Q a�SS tL
��cenify tha�in tha performance of tha wark for which�his �� - � �
permit i�issoe�f aholi rror emplay ary person in any mormer 5� �^ f ..'A� .N ov _
so m ro becoma subiect ro the W orken'Compensation taws. � flisr�was�ER ��p�
0 1 �l c
Dota °PPlicent � � CIOTHE3 WASHER p p qpqpF� ,.`. O ,( � i
NQTiC�1�APPLICAM: �f,after mokin'g�h��Cemtimre ot w �
F�cemption, you sAo�1d becorne su��ecr ro Jhe 1Norkers' SW����O� ?
Compansation provisiom ef+he Lobor C9de,you myst farlh- ���5�� �� G�IJ�D i4' 0�"�'$$ y$A
with rnmply wi�h wah p�oasWnp or this�permir shall 6e - �TA�E � . .IIC. .�.
deemed�evvked. {aa�t�ntt�a t�.�NO. gOO C5A55 G ;
UCErlSED CoiViRAcroRS QEC1Arun4�1 � oisrxicr No. �(1/� er ;
I hereby affirm ilwl i am�licMsed undbr pwisianp►:Ghapre�9 11�,l3YSiFM OUItETS O'17 � �5\ .�'�^A � �
(eommmrirg wBh Seceion>000)bF�Ivlsion�of the�uafnns pUTlFf50VER /� .
atldProfessionsGode.Crldml'��[Ms0�7in�tlUfa[OOMIQHed. 5PERbYSIFM ��Q � fINAI � O �
VALIDATION
/� ��/� DATE V �
Licensa Number^'���.���a ,. .�'c.Gass_.S.e_]J.� .. ' �fpVAl �
Gonfraetw �{Mtg �'�eB�R�� BY . O .
� W ':
1 om e p�nnder Sec. d .
y i
s.aa.c.fw rh��.ea�o� - - Plqn che�k#e� . ` Z I
Dore: � . . p�uMBING PERMrt ISSUING fEE S p .(, � a 1 1 2 9 A j
signo,,,re - . .
. TOiAI FEE �� (� �� • . � . i 5 �
- Plon check appiican� i
SINGIE FAMIIV I • .� ��..Fi 0 '
HON4E OWNER-BUIL�ER DECIARAflON f4ame � � . . i
I heroby affirm that I am erzempr 6om the Conhecror's lieeme �re� � • ; � a G.j r� �
law fw�he following roason(Section 7p3i.5,Bvsinpa o�d �
Profeaiona Code): UN TeV.No. 0�.2$`a 7 -. �
❑ I,os owner of�he�propMy,will do�he wo/k arrc!�he . � � �
atruchire ip not intended w offered for sole(Seelion � _ . _ .
7044,B�sinesa a�d Protessions Code). � �
CONSTRUCTION 1FNDING A6ENCY - - . �
1{�ereby aflirm thut�hero ie a ewunuction lending agenq for � � '
the performapce of�ha work for whieh this pprm��is iswed � .
(Sac.3097,Civ.C.). ' . _ �
lender's Name '
j
Lendar'a Addroas � -
I cenffy�har I have read rhi�applicatlon m�d atata�Frot the . . . . ,�
above infamotion is conec�.I agrea fo comply with all�ovnfy .
adinanses and Sroro lowa regulorirp Pl�mbinq,and hpreby "
authwiza representatives of thi�Cobnry ro e�ter�pon the � � -� - . � ;
above•mentioned propehy for inspedion purposes. .
SEE REVERSE FOR EXPLANATORY LANGUAGE
Q'�
Sigrrotur f ermittee Date � . �
� _ _ _ . .. . _ . ._ . . _� _- - • ---
' ' . No Z 'r-' N C O N N O Z
� m„Ny D { m � { � � = A
I .. v D Q ~ � A '"'� � C `N V
I . O � -�1 �n O G �
I D ~ m D Z � �
v i^ a� � x v�
� .
i
� � �
I� Z �
cn ;
' ^�` ' 1
. O a �
A (v
' `" 3
� o �
4 � Z
�' � �
I. . �
r �
� � (%N
N '
� - �
D
c
A
, m
l
�
i
h
�
N
�
�
�
70
� . Vi
• Z
0
f�
N
I
I'
I
I
I
I
f
�'
i. . . . . � .. -- '
r , O d V N tn(� -0 p � to r—
� o °° o °. � 3 ' o �° mo °aW° o � � oc ,� N � S,
� co Q° 3 o-o� � iroMn „ o M � = 3 � e � ; � u
i: • , � � � `.� < a�-�=`�c Ow o' `"o n� � 3-�� � N m °�
, n x o-c m $3 � Q" �%+o^�- ��+ A. r� � � �c
; 0 3 $ am ° o,�' +o u `"; o.��- � o o�° � f °,
-, a � m3o � �M �og'.�'cw" o�,-���'coa _ O
s � �1
c b � N �� � 3 � ; ' o as$,$ _� � 3 0 0 3 Z
a
. �; � O �p � � 3 �M ° ° �?n ° Oa07 'c ' �; T m
, o o � o`ao ao u Q � o, 'o_o + u u °o o� g o � Q �
a n'
� , � c��' . � s3-oT� .�a., '°'v�-u a "? o � �a� � � � o3 -
:m � m`° Sc 3 av 3 o a n `"'nM sv 'c o f n �
' vc� ,:� °'boM °vro o0 3 �Qcvo =2'� A
i
.. � p.� S 7�� N ��..� 7 O D� S b � ^ p ., v _ �
m
: . - o �mo ' o' � �� o � 3-mn 3 ° � j � � n
4 .. " a �Q �a > > oa£ ° M� oq' m'°3-o '^ �.� � 'o . � •
3 � r
° � o � ° F � � � ° � � o' 3 N 3 'o n o o � �''•ny
. � p� 3 Q� Q 0 y O � �.N � O �" 3 C p � A n � ��i � L .
' `sn e'M a°.�� f o � o a� � o�� ac° � o, ,
�-� aoNa � F �Q �m�,a � 4°3 '` �+0 � -
i O • j � H b 4'II � Q'O �.� O O �w n �
i � � f0 C f! � O � �O F C O'
. a�° ° �� � a c�� � � '�C �m m m �-; i.� �
�