HomeMy WebLinkAbout1301A (7) WORKERS'COMPENSA710N DECURAi�ON APPLICATiON FOR PLUMBING PERMIT �
� I he�eby affirm that I hove o ce*ti6w�e o oroe��io cel( �t,qyy�q
[ �nsu.e,a o cern(ka�e ol Worke�i Compe ti Insoronce, CE aq iRtv.t0�8t)
� o.a ce�hfipd copy�he�eoi(Sec.38Q0,ta GOUNTY OF LOS ANGELES BUILDING ANDSAFETY
acy r1a. (ompony
<ertiHad copv�a h�reb�furnished
coa 4onK�nr ro Fni w r,wmr ox r��I n���ts �
� Camfied copy is filed�.�rh fia co�niy bu�ldirp ins _
�on dePo�mem. wutaa6R c�xiuR[at�itt�n � rte
loFJltl�Y
�t . �" r��P��� ` �f WAiERCjpSET
n�EA
CERIIFlCATE OF N FROM WORRERS' BAtn iue 5i.
4�OMPEN TION IN$URNVCE ��p OW1�R
ih,�pimut i far an�handred d Ilan(f1o0►orkl.ss_jwd bY �
LAWAiORY ppp�¢5,5
i cemh+hoi��+he pe�ormaMe a+�he work for wh�cA�h�s Q �
perml�i�iqued,t fhdll np)empioy onM per3pn�n a��man�r SNK Crtv �EL NO p�3 ,
so m�o become wbjecl Io r{ro Wprkprs'Compenwlion lawc. p���.R . .
�CON(RACiOp
DaTh °PPlicuni cLOIliES WAShIF.R '
NOTIGE �O APPl1�ANi: if, alror rra4�wy�h�s Cereifico�a oi ��� � j
Esertmfion, you sho�ld�re�.vme wbjec< to �he Wohen' SWiMMINGPOOtRECEPTOR
oompe��rn�a�P.ows�ors oF+he iab«code,ro�mua�forth- IAWN SPRINKIER SVSIEM arr r�i.No.y y,?•jp� ,
wi��pmR1Y wiih urch qq�iaom vr �his Qerm��ahofl M ST`���� � l� � • .
daCmpd�C�Oked. WAfFA MfATEN
U�NSED CANTRAC79R5 DEClARAttQN - oisrmcr wo. er ;
I haelri aPorvn Aa�I qm licarq4d wdx prw:sioro oEChaprer 9 G�S 5v5rEM OUr�rs �r .
IcammMC"19 w�th SCaion T0001 0;4�vi:io�3 ot qle Bu�i�tt OU7IE15 O4FR �'` .
and Prdtemtms cade,and my nce�se 4 in full f�and eMx+. S aER SYS7EM DR� VAlIDA110N � ;
LiCen7eNumber �� assS,-a�3�. � �� Oi :
FINAL O ;
�_ .
ccnncero. ome Z eY W .
� I am e.emp� m Sec A
� @.BP.C.far�h:s rea:on pinn check fee � Z ;
� Do�e. PlUMBiMG PERMIT ISSl3fNG S�E f ��1 3 Q 1 A i
Signa�me 1• • • • •:;
TpT[LL FEE
� vlpn clreck oppl:rant I � � � �;J l�- .
SINGLE FqMILY
MOME OWNfR-BUILOER 0'KIARATION Npme ' I C+;J��'�;
I herpy�elf�rn�Aa�!om e.empt hom the Co.�eoc�o�'c Lrcense �� !; �,„G—O�l �
Lnw fpr My following rcoson(Sec�ion 7031.5,6usineas and
Rofe�siom Codel: Ciry Tel.No. �
❑ I,as owner o(ihe o �,w�ll do�he work and rha �
C� Der Y
shuelvro Ss nM inMrtdad a nNered foi wle �Sec�ion ► ,
70de,9�s:neas ald RoFesa�ons Code).
CONSTRUCTION LENDfNG AGENCY �
I herebY affirm rhor ihero�s a construc�ion le.,d��g ogency to.
the peAormonce o�d+e work tw which th�s pe.mi��is Issued .
ISet.3D97,Civ.C.).
Lendar i Noma �
Lenda's AQdress
I cernfy tho�I houe reod thfs opppw�ion ard smro iho��he � .
a6ove in4amat�on is correcl.I pyrge b comp�y with oll Cou��y ,
ordirwncps o�d SM�e low�requlaling Plumb�ng,ond hereby
authwize re(xesenlurives o1 this Coun�y+o en�er upon�he �
obore- i�oned�erty�Wec�ion Gu.posm. �
(� SEE REVERSE FOR EXPLANATORY LANGUAGE
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SiB^alyre of Ferminee Oa+e �
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