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HomeMy WebLinkAbout1591A WORKERS'COMPENSA7�ON DKLARATION APPLICATION FOR PLUMBING PERMIT � ' 1 hereby affirm�hot 1 hore a cer��Kcote af consanl to self ly4eyq cnsure,o�a ce�hf�ca�e of Wwkera'Compenw�con Insurance, CF ev(RFv.�oiei i � or a cen�f�ed copr�he.eof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. � Cpmpony ' � Csrt�fced copy�s hereby furnishad. . OfOR APPLI�AM TO F�l W(iRIHT OR T'OE) B��S �3�p�0 t� Y Ceniiied copy�s fil�wi�h�coun�y b�Hd+rg�mpec- t�on depanmen+. NUM9Ex POIfURe oR rtEM � iEE io�w*Y ,aN�o�rd C.�e. / 6s" Dote�_T_AppliGont WATER LWSEF fJEARE57 ' CE1[fIFICATE OF E7(FMPTION FROM WORKERS' Bnfn iVB �ST� '�w e.�k �.� � CAMPENSATiON INSURANCE S��p owwEp ��,p�� �'.. �' . (Thl�sMlon navd nof 6s eemptofad if Tha nark inrotr�d by � tha permlt Is foe on�hundrod dollan(SI00)er tass.) �yqppRy �'�� � Fi, S ADDRE55 I cenily thai in�he performonm of�he work for which rhis � permit ia issued.I�hall no�emplor 4^Y Pe�son in any manner SINK C�Tv � a� iE�;.Np.�I���3 . ao m�o become sub�ac��o�he 1No�ken'Compe�natiqn lowa. -0��w�p � � /� CONTRAROR Oote e^�ieanl !��`�� CIATHES WASMEa � NOTICE TO APR1GqNT: li, efter 'king�his Ge�M�mte o A�R� Exemp�ion, yov �houtd becom a�b�en �o �he iMorkers ��������'� (.ompenwiion prorisiorn oi�he Labor Cade.Yo�muy fonh- Giv 1F1.Np. , with r�mply wnh suc� po�is:pns or !his pOrmit ihpl', be ���INKIER SVSIEM STATE LK. � deemed re�oked. yyqhR�pf¢p ��J .� ��I10Erv5E NO. CiA55 IICENSED CONTRACiORS�ECLARA�IQN rn57RKi ev0. D ev I hpreby aHirm tFqt 1 om IitM1SBd undC�p�OviSiO�y 4f(nOP�C�9 �SVSf6M ' q,17ki$ /� -`.t/.�� ko�nmencirp w+�h Senion 70pp)of D�rision 3 0�Ihe 8us�ness OUlltTS pVER �' o. ard Professiom Code,ord my licer�e is in 1�11 fwce mdeffecf. 5�Ep 5+51F�N FINAI ' i VALIDATION O DATE ��' �C V lir.prrse Number Lic Claa c' p� ' FlNAL,.. . � � • i Ganfrotlor- , . Date - ' BY '....1�I..i�'-� V � W I pm exempt�nder Sec. N ' B.BP.C.for thiy reason Plan check fee Dara: PLUMBIIVG VERMIT IS$UING fEE S f, ��J : � �r.I r; Sigrw�ure , `- . TOTAI FEE rr.y�"� . e � s a . •j vi��h�a�iK�.,� I • ::C�[' �INGIE PAMILV ' MOME OWNER-BU1l,OER pECIARATIOIV Name _ ' I hernby aflirtn thol I am exempl 6am Ihe Conhacfor'a liceMe ' v •:�i�-�.';: lpw For the fulbw�ng raason(Secfion Np1.5.Business ond �� ^ . Aofessione Code)' C;ry TeI.Na. G�:iL•-f:�- � I.as ow�r oi�he p.operty,will da fhe worG and ehe , snucwre is no�infended a oFfered far wle(Sectivn — 7Wa.B�a�ne�s ond Profess�ons Code). . CONS�RUCi�OM IENDING AGENCY I AarebY offirm tlql lhna is a construction lending agancy}a �he per(wmance of�he work fw which rhi�pe.m�t is iuued LSec.3097,Civ.C.). Lende�'s Nome Lender's Address I cen�fy tlw+I hove reod rh�s applico��on ard sraie thu��he � above�nfama�on is conect.I ogree�o comply wiih all CouMy mdimnces and S�a�e lows regulot�ng Pl�mb��g,o�d hareby ! ou�ho��:e repmema�ives o! �his Couny b eNer upon the . a6ore-men�ioned properfy frn inspecnon pu.poses. �,���,, � SEE REVERSE FOR EXPLANATORY 4qNGUAGE ���'� � r , IS' o+ure of Pmmnree Data , � � A C C y r p ➢ v� U �i '*.` � '" N " � 9 �l N i/�G' i� � r�'. tL' S �tl b = t^ �� 7 a 7 7. " �. "v _ - :,ic Q �'' Gl � G� C o� j; � c'' ' " '� i U a�' 7 .�`.' � C) y �? -Vi C � G1 7xc �. . - �'� u vL� 1� 1� _ ' I y _, �� Z � N � �� � ���..,� — � ^ � N � � .-� tn � N 2 � D _� G � Z � � O � � � 4 U - n � �n n 3� ° w c �� - R_� � � u'' �0 O C ,q �` ' ? o y � � E in� o j u � = -±� M � C. � 'N r � � o =°� n . � T 4 N �+ ;; � O p p °�ro � x.� ~n '-"- n v�T n� � �. � � n G*� 3 rr� on, v-r' ��,cU'" ° v� o „an n'' ap ., c � < < O �C � �� `wp`t n �R , o�c Lr = ? n .� fB ' O'� O. '4 �[: t[n� ..A.. �r i�� 7 C " . CJ �l @ O�? p � u4i'o y jb � U�•�7 O 0 r _J� � � C� � � �� 3 m ..o -••o Q� N } ncL•- ry - n ' " r� - �� x � 3 � � f � < '' �iD'�D_n � o' A =n 'c N• j C: � < O '� Q _ ' . '^ C � ;r Cl�"c]"9 �A � ,,-^ � � � N' CI O [L N r �� �, O L� r.' fl (' � a O a< � Q� = � "Tl � .: 2� n� - n�� � C7 E � II 7 `�C D - � C O �' :C V f/1 O� O ' N N O 'V �y� O p % f.1 A N � . � C:.- f. o n :r?° p o i='= � _ � o c" � : �,c: �'. � !+ �-m � R �� � r o � y� �o n � � �� � A cr o _� '�� N "� j:i j -t%; `'o �: i:, �� 1 Rj c' � ... � � � in n �_, tg _� R _/' ; �. � TS �D�t O S � O M �' •. C :1� R m �V :) C Z � U 7 01 i. � � r r : R� _: C � M f' �.N' � -r � 4 0 O �� C'D 7 .. O L. ' �,r C: Cl 3 U T7 q� �, i :/�• �J o TI O � O �-O C�j C o � ^ N 7 n c p O n � � „o .�- � ` ^ �� ., u ., m ii c N i � � � n i; " n u n '� t� - ... - " n c � �� n <. o z 3 •�� ii :. � N -� 4 '� � '� r-_ -' � ti' � n r. � =r �� x .� c 2�'n n :� � �� �: i �; u�� c,� r c,o < _ --_ -� �, a.,_ : �. . =a c ' o-� n o ��.;.��� �u � N � c �.::�1: o -- �, ' : o i�n � � � ?' c ii ^_ c o _' :i � - ; �,. " ^. � _ . � ... v � �, �' � i; , . .s ' . � ` ��O C n � Q ^L:_ ti.��_� ��._,.�• .^•�� ��