HomeMy WebLinkAbout1697A , ��ORKER$'COM.PE'�SATION DECLARATI'JN APPLICATION FOR PLUMBING PERMIT ���2�' �
' I her�by aHirm th�1 I hovrt a rerii(imre a(consent la ulf �h,.,y��p \ . \
� p� � �� �.�,��,,(^� \ \ �
insurr.,or a ceriificaie of Workers'Cnmpe�sa�ion Insuronce, CF BI7(REV.70i81} 0.�
c�a ce�id��d cepY�herrof(Sec.9AW,Loh.C.) COUNTY OF LOS ANGELES BUILDING AND SAfETY
�cy No SL1�"�W.S�_Cemponv�l:.�C]� ... .
Cerl�f�ad toAy is heraby fu��Isf�ed.
FCR fiFPIICAhT TO F'tL IN(PPINi O4 TYPE) !'URD'N`^.
��Ceriihed copy�s filed wuh iho coor,iy bu��d+ng inspec- f.D.^.RESS
��o��pr�.�mF � NUMdf7 FI%TURE021iF.M (r" FFE ,
�T' (� lOCaIITY
Da�e��Ap,licanl� 1�P1�JOhS WA7CR CIOSFT ��4, �
� fvEn4(ST
CERTIlICATE OF EXCMPTION FROM WORKERS' BA1H iUd CRO55 St.L bh 1 '�G
COMPENSATION INSURANCE C'7JNF � � � �
(Thi��xflon ne�d no�ba compl�bd if thr work Inrolr�d 6y � �u�`�C4 " -
`�A!l
Ih�parmit is fo�ono Aundrsd dollors(5100)or I��s.) L�VaiCRY 11CDRF55 _ "'
1 ceriify ihol in rh.e porfermonce ef the work for wh�ch ihi, �
pe�mH is issued,I shail not employ ony ppraon in ony monnpr Si�:K CIivC $��\A e SL+ /�_ . �12'2 �
so os ro become subject lo Ihe Workers'Compensm�on Iaws. \'\ J Lh^ ^-�G. 'J
1 DISH'NAS14R � -� �OtiTRAC10R r� � `',�S `�� �
L � r
Dole AFlPliconl 1 CLOiHf5WA5HER �
NOTICE i0 APPLICANT: If, nfier ma4ing �his Certilitate oi �DDaFSS� �
yemp�ion, you should become subject ta ihr Workni •`+f'�!�.'N��LR[CFP?OR GT � f� pr' p t
�ompenw�ion provisinns oF Ihe Lnhar Code,ycu mus7 fonh- ��y,�N�oai�;v,irosycrr,y. ` V � ` n I�1��L'11��"fiL.7Q
wnh comply wuh svch provisions or Ihis permil shnll br. SfaTE 1�G �'
deemed revoked. WnTFR HFATFR I ICENSE NO L�� C1A55 3
LICENSED CON7RACTORS DECLARATION '— rnSrRiCt r�o °vc SSED 5r
I hereby nH�rm tFo�I om licensed under pro��s�ons of Chopeer 9 CAS SYSTEM OUTIETS ,� ��
(commencing with$ect�en 7000)cf Divis�on 9 of fhe B�s�ness Uu�tEi50veR
end Pro!ess�ons Cafe,and my I�cense is in full(orce a^d r.Hect. 5 vF4 SvSiFm FINAL VALIDATION
(��� � DATE 5�Z'_v O
License N�mber�'�110�� l�c.Class�
Q �� � _��� FINAL U
Con�roc�ar R�n.�e��-S�� o����G� AY �µi Lv
❑ �
I am exempf urder Sec.
B.RP.C.(cr Ihis reoscn , W
Plon check fee p„•
I
�ate: p�UM3!NG PER.MIT ISSUING FEE 5 Z
j Signo'ure ^
I TOTAL FEE 1
� SINGLF FAMILY P�a^�heck opplicani
. HOME OV4'NER-BUILDER DECLARATION Nome
'�+e.re6y offlrm thot I�m�.Pmpi frem the Con�rnctoi s ticensr. qddress
�y i.. �tie(..ii., y ".,,. �c......,r 70�:.... ��.�,��e ond
rieiessions Code).�^ Ciiy Tel.No.
❑ I,os owrer cf!!+r,prcperfy,w�ll do rhr.work�n�{�hrt :.1 �������
strodure is not if1�P�(�P�cr oifere.d for sole(Section ► �
70a4,Bus�ness a�d P�ofess�ons Code). �, n . e e j
CONSTRUCTION LENDING AGEPJCY
I heraby nNirm!hni!herr is a cc�strutfion lendinq oqe�cy ior ,, s e o .j
ihe performon:e of ihe wcrk fr.r which this pe�mi�is issue.d
(Snc.3097.Civ.C.). � ° � � ?;;�
lender's Nnme " " � I t' ::!1�_�
LPndei s Address
L i+CC—C:
I cartily rhot i hove,rer.d�h�s orn��coi�o�o�d s�ote iho�!hr ►
o6ove Inic��^oKon is cerecl I og•r.=to con+ply wl•h oll Covnty
crdinnnces and 5'o�e laws regulartng Pl�mh�np,c�d Fereby
ou!hcrizn reF�eientn•ives cl this Ccuniy ro emer upen Ihc
chove�me��ion=d prc(:crly fcr insprct:on purpeses.
SEE REVERSE FOR EXPLANATORY IANGUAGE
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