HomeMy WebLinkAbout1565A WORKfR3'COMPENSATIONDKIARATtON APPLICATION FOR PLUMBING PERMIT 338/A � �.
I here6y a11�rm thai I hore a certificate oi consent�o self �y�q607q
inryre,or o cernf�co�e oS Waken'Compe�sa�ion��suronca, C187�(RFV.1W01)
. o,p cer�it�ed copy�hereo4(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AfVD SAFETY �
P�,i��j],771 D 7 �o,,,�,,,,y Fi r�nm�'c H1mri
Q�Cedified copy+s herc6Y fwni�hed. �
� FOR APPLICANT TO FIt!M�PItINt OR TYPf) e�1 3 Porto Gr -
Cani{ied coPT�s fited wi�h the couny building�nspec• N�MBfQ p�xTURE OR I(EM o FEE
�� +ion deportment. lOG}tTY
�� 2/6/84 ��;Sa��RCR bY• .A WAlERC1aSET �$ _ �s�Dienaid Bar Blvd/GYand Ave.
CERTIPICATE OF EXEMPTION FROM WORKERS' y enn�Tua f��� -
CAMPENSAStON IN541RANCE ',��R 3 ��R ;LCi3�.Ey Of SQ. C317.f.
(Thi���d�on nNd nm b�eompbtad it Ihewer4lnvolv�d b� �
tl`ie p�rmlf Is ter ena h�ndnd de0art(S1C0)ee Ins.) iavaroxr — novrtEss�t600 DY'j.V2
1 fan�fy�ha�in�he perfama�e o{�he wvrk for wh�ch ihia �� G ,_ C�tv iFl.NR �
(flrml��a iswed,I shall.q+ompioy ony persan in rnry mon++er � .
!ry os�o beeome wbiecr�o�he 1Nakers'Compe�aOtlOn laws. �Wpy�ER j` �
Car]fw�CroR R.C..R. Pll�?� IiIC.
Qpfe -APP�'mnl uO�i�w"�"E° ^��12 85 Lia A
YICF �O APPLICAt�f�: If, aher mek�nq�hia Ctmhmte of ������ '
i jr�p�ion, you :hould become �ubjec� ro !he Wlwkeo' Ciiv fFl.Nq. �
-kpmos^aotion Prov�va�s of�he 4aba Code.�pu mver forth- uwiv securxL4R xvctEM •
with caodr '+h syc�h Vrww�o�c or tb:s pe�rmi�ahaii � ��No. 336428 �UA59 - 6
�Oemed roroked. vuAhR H�.nhp •
LICENSED GONiRACTORS OKlARA11QN qSTRIf.I NO D BY
Mheraby alfmm Rq�1 am limmed urder porisi0ns o/GboWa 9 Gni svs�rtn ourrETs
�ommenurg with Section 70pp)oi DiY�siQn 7 of�h9 Bveiness OUILETSOVER � �
Ord Profa3Sions Code,and my IjMnse is in fiA{fOrce Qrd eNKI. 5�FR 6YSIFM �
Fwai �s/ VALIDATION a .
336428 uc.c�m� 'S.�- �].�_ �� ����, v
m
Uceme Numbe� FINAL � O .
[o�nocrorR�P� T^ ino Tn��e 2/6184 e� � .
� I am eaempt undm Sec. � N '
Z
8.8D.C.for�hn.eoao� P(qn c'beck#ee `► r �
Date:�- PlU7A$1NG PERMIT 155U1NG FEE 3 Q . I ��'.::r�
Signonneti TOTAI FEE �'(? R • . � s .j
Plyi ched apPlicant i s �'..�.'�`r..^,v
SINGLE FAMILY •.
HOME OWNER$ULLpER OEGARATION �9�+� R.C.R. PZ+I�MBIlVG INC. - ; x
�eby aff�rm+hot I am examp+from tfie Controcta's liceine ��� �"�7Sr�M�,,.,0�.28�1V2. . .• •`•. ,.�.)`.
ior H+e follow�ng.eaxon lSec��on 7p'l1.5,Business a�d . ��f�"
Profms�ons Codel' G�y Tal.No. G!-� �-F�l ,
❑ I,as owne�of rhe proper�y,w�ll do�he work and+M �
anunure��s no� ���ended w offered fo�w1e(Section ►
7Q4�,Busineas ond Rofessions Code).
CONSiRUCT10N LENDING AGENCV
I hereby alfirm�ho��hs�e�s a consnuciion lend�ng opency for
�he perfmmance of rhe ww4 tor which thi�permit h issued '
(5ec.3097,Civ.C.). ;
te�de.'s Nome Securi.ty Paci_fic $ank
le�er':Address N"^Y"�� B��r �
1 cornty�hat 1 hure�ead thi�appl�cahon ond�bte���he ►
above infamo�an Is cwreci I ognee to comply w��h nll Coun�y
ordinvnce�and Sta�e laws regu�ati�g Pl�mbing,ond he�Bby �
au�horize�epresen�o���as of�hn Coumy ro emer upon the
abo.e�r�e���oned pope.�y for�ropepc��on p�u.'posee. SEE REYERSE fOR EXPIANATORY LANGUAGE
RGR bv .�..14,✓�" 2/6/84
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