HomeMy WebLinkAbout0779A (4) � WORKERS'COMPENSATIONDECLARATION /�pD� ��'ATI/�wl �^� �11�!9.Q,we/� e�r^:�IT
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I he�cby,,o�,mllhui i fiovet u certinm�e of consent to seii in- �,����p '
. sure,or n rorti(imtc of Workers'Com�ensotion Insuranca,orn CF 8n IRtV.e%861 � �
= rer'tified copy fhereoi iSet.3II00,Lob.C.; �-
� Policy No.7�Jd.C9�5Q4�(d9lFl�nyDJB7'IONWTDF.___ COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
z � Certified copy is hereby furnished. •D T• :42578
y �- _ FON APPLICl�NT TC)F_Li:N iPR�Ni UR TYPF; 8��i���N�'
Cer;ified copy is ided with ihe m�nry building�nspedlan F��k`S:�Q$_ S��TH LEYLI�ND DR
'j depar�men+. NUM6ER FIXT�JRE UI2 Il'eM � ��C ---`
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� Date9-1-8R A hc * _ ... -... ,_
�,en;sVsi
o?ION FROM WURKERS' BATh�I?:1B I �_. CRA�T��{j� _._.___
n� COMPENSATION INSURANCE� �� { n"�NER
s!�ow�R � i I _��,I��Ell-
(This section need not be comple1ed�f the work involved by ---- -- � ---��� �--5-�-� t v,.�il.
� fhe permif is for one hundred dollars(S1Q0)or less.) IA\�A?OkY � I �AJDRFSi ��S 1 ATRj�T
7 I certify thai in�lie per(ormarce of tF.o evork for wh ch this perv - -- - --� ---�
� I P Y Y F Pr:n Y �— D S 1WASNEI2.'_'_—_� ��TRAi r��OSTA MESA ���. NU
� mrt is issued,I shqll na�E�m Ic on �erson m an manner sn
as!o become sob'ect to the Workers'Com sot on Laws. � ��
y � i«�..__ qpon�a� — I-��-oi ir �>sr,ra T- l, H NLW Pr rrnau7nr� �kAC_
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� �Ce ro n�Pi ic'a!vr i+ e+iP� .k�,g h�s c�.r��o�e of[x r i -i 2141-S,r ni rnnnrT__DA�V�
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SWi.AMIfvC P('OL kE EP7Uu �---
� �ion,yau should bec ,sub�z i� the Workers'Compen- _ .� _. .� r,._..�-���,iv _ - i N:, _
so.on prov s ons of ihe�nbnr C<da yo i0s1 forrFwdh<�oinp- I qN�So41NK.ER bVS'EM -� � � A'�IAAFTM
ly wf!h s�cF provisions or ihrs pe n sh li i�e.deemed re�ok �_ _ _ �-�i`n, .
� ed. , I W!�ER !tAlcK �. _� \�E ti� � .A. -
a �!CtNSEOCONTRAC10R5 ;iC 4RATI.^,N �—� --� - -- -- ----f- � - JIbtBIC�NO RUC�SSECev
J I hereby affirm iha�I om licensed under provisipns ot Chapter +�___.L� fI�GAS SYSTLM � p�i�TS i � `•+''�
d 9(comnu•ncirg wrth Sr.ctioc 70C^';of Div�vo,�3 of 7he B�s��,ness " �OL�r,____—_ .._. ._—T- , _. _- _ F v�_ _—
I � I
i a OVER
E and Prcfessions Code,and my license i�in f�li forcc and ef- �.. _ ��FER SYSTG.n ___I ; � FlNAI ;/� � ?-
; �e�i. oarE 'Y/.✓-.(�/,�`� � ALIDA710N 0.
� license Number/�.2,(1 nQ Lic Closs ('-�h - - � I - -'- �
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i _ ._...... ._ __. ._ � , CL
I PiNA �!
Comraci�� NE.W PLUMBING Dore�1-�$_ -i- �Y ''.�su'xt-�"' C?
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� _. .. . __.. ._�_+_._' 1
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�, I am ex�mp�under Sec. � 'u,"�
�__.—
j, .--. _- ---�--- , es,
a aP.�.ror ra�s r�aso� f�lan check fee I � . � �'.'`_ ' w
� ---_ -- .--Daie� --�=--pLUMBING PERMIT ISSUING FFF S� � . `�,,. � �
� Signalure _..__ . __ --- ---- ' ,, : „
i --_ -- TOTALfEF , , ..
{ SINGLE I-AMILY � ..-... � �$ i " � �,r:.i. �.,
� HOMF OWNER�BUIIDER�FCLARATION P�an check app!icont _ _- J
I hcrehy offirrn!hnt I om eaempi from the Controctor's Lir.ense Nome � �
{ I for fho followinq r¢Uson �Secr.on 7031.5, B,isiness and � --- -- - ---� -
f1 :ssions Code!: Address �s � �
�i ❑ � . - � .-._.... _.
I, as ownor of the proper!y, w�ll do ihe work and the City Tel No.
� structure is'not iniended or offered for sale(Sectinn 7044, -- -
Business and Professions CodeL `
CONSTRUCTION LPNOING AGFNCY p
� I hereby�ffirm tfial ihere is a construtiwn lendiny agency for �
th=prfo^nance of ihe work(or which this pe�mil is issucd ,
� (Sec.3097,Civ.C.).
Lender's Nome
# Lender'sAddress __
� I certify that I have read this appllcation and state ihat ihe
� above information rs correcL I ogree to comply witn all County ,�
ordinonces ond Sfate laws regulahng Plumbing,and hereby
� au}horize representatives of thrs County to enter upon the
a ve-me �oned property for inspecho i purpos�
; SEE REVERSE FOR EXPLANATORY LANGUAGE
� Signature of Permiltee �nta
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