HomeMy WebLinkAbout1686A WORKERS'COMPENSATIONDECIARATION APPLICATION FOR PLUMBING PERMIT ��� ��' �
. I hereby oifirm thai I hare a ceNificate of wnxn�io self 76A6yq �1�� �1
imuro,or o cer+ifimte o4 Workeri Compenaa��on InsurUnce, (�817�REV.IOiBi� �t''
or o canified copy thereof(Sec.380Q,Lob.C.) COUNTY OF LOS ANGElES BUILDING AND SAFETY
��Y No. —�a� CompnnY��-�!C �u✓lu�. � .
Cer��Hed copy�s hereby fu�n�shed.
FOR APPIIGM TO FILL IN(NtIN�OR TYfE) BUIIpIryCi ']� .
�tertified copy is filed wi�h�he counry bu�ld�ng in c- ADDR�SS � J�J
hon deponment. �. NUMBER P�MURE OR ITEM Q FEE •
Q �� ��` � �µ� V 0.
ppteQ�:.�{0�,6.b Applir�on . � � �j WAiER C106ET � NEAREST ^ .
[c065 Sr. �
CER��F�CATE OF fXEMPT10tJ FROM WpRKERS" �IK'J Z BATH TyB �J Zr �
COMPENSATION INSURAN� ^ -
(Thl�s�cllon nasd nef M cempl�t�d IF th�work liwolwd bY i— SMOWEp � � � � � C� ,
�h�p�rmlf h for ons hvndnd dollars{=1D0)or Ins.l S u�nrdtr �qpD��i �' ��
I cen�fy rha�in�he perfwmance of�ha wak for which�h�s .
perm��+i�aued,i nholl no�employ any peraon�n any mpnnar SINK � .� GTY C��,� �y. ' D�
ao m ro be�ome wbjec��o�he Wmkera'Compenso�ion lw+s. p�W�ER
- �'R"� A t a.. �
Dcra epplican� 1 ciplH6s wnsHeR A�� ,
NOTI�i[i APPIICANT: If, C}ter moking R�n Certificote oF Q gw���`��� O
pHon, you should beeoma �ubjece �o �he Wwkers'
� i � 7E1.NO. 7_
I: lmation provis�0�i Of Ihp�bpr LpdO,y0u mySt fOHh- !AWN SPRINK:ER SYSTEM CITY � �
� with eomply wirh �ych provisio�a a rh�a permi�shall be g1A7E � / !
deemed re�oked. Wp�p�q�p � �cFf�SE np. `Y 7� � � Y
LICEN$ED CONTRAtTpRS DECIARATION DLSTRKT NO. Bv
1 hereby nffirm IFwI I om iiconsed under proriaiony of Choplm 9 W�5 SvSiEM WT1ET5 / 'O. �/� ,
�eommencirg with$xtion 7pOD)of Division 3 Of Ihe B�aitless pN1E75 pyEp �� �
ord Rofassionf Cada.and my lieense is i�full force ond eHect. 7 PER SYS7FM � >
Q DAh� � VALIDATION p
licpnse NVm��ia CI a�d� L-30.� v .
�j fINAI �
Cpnho[to �f9' BV �
� I om lRGmpf urdlM SOc. W ,
d
s.a,v.c.fo.�h�:��w� Plon check fee ► ?
Dvte. PLUMBING PERMIi ISSUING FEE S
Signature �
70TAL FEE
Plon ched appi�cam i
� S�NGIE Fnmur �
HOME OWNER-BUI(.pER DECLHRATION Nome
"�e.eby affirm thoi I om exempt hom�ha Contrac�or's ticeme
�fw the foJfow�ng reas;,n�Seci�on 703i.5,Bus�neaa ond �`°"' - j
� .�essions Cods): ��ry Tel.No. ' I C'i:C h
❑ I,as owner of the � 11 do Ihe work ond rhe u e e + y =- �
MOPer Y•u" .� ..
anun�re�e not inle�ded or offered fo�so�e (Sec�ion j
7WA.Busineas and Profeaiw+s Code). . � ' � I �`;'J i
CONSTRUCT�ON LEND�NG AGENCY • ' i 1 _� —
I hereby offirm�hof there i�a conshutfion lendi�g ogenty for '` �'"
the performonce of�he work fw whith this permi�is Issued ��^;�:;_`;� .
ISec.3097,Cir.C.). . . • •
Lendm's Name �
Lendx i A�drass
I cer��fy that 1 have reod this opplicallon ond s�ofe tFq�the ► .
abore informarion is correct.I ogree to comply with oll Couniy
ordinonces and Sta�e laws regulming Plumb:ng,ond hereby �
aulhorize rep�ese�kAivea of�his Coun�y ro emer upon the �
a6ove-men�ioned p er+y ia inspec�ion purposes. ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
C
S�grw e o!P �»ee pa�e
C
G1 �l �:
11 � 1 C. �:
� � G C� N � G� .0
�, r � � �� �.
� �'' �: r �' � '? T, �`i
r l y '< .�" 'l, q, L �� G �' U
��G, � C� �� �� � iP � �.
S U T� �� �
��" � � T
. ..�� a � ,x.� �� (�1 x �
C: �•
:�'�, �� A' N
� �� ��
Z; J
',3 , ` J�`f\•� � i\�,
] � � `
e �`
\ h 1
f h �,�\ c
' ` l
��1� � J � �� �
\ �
n U�
7 N
� in
G�
� x
�
�O
�
�
?-
`'-o
��
p
' N
��
M
�
r "
� � A � fl �
N 0 q �'� �G 7 ✓ �.
M �y
R n 0� O n '�,?, t�, 0 q v, � .c
T O 'y i 4� lY O J�.� � Q O
�t ��A O i/�7 f�> ; O 0 � C 7 � ` O
?,f T r N 'o ° $,,�o .�� a� c:. � ,
°�'° 4 �� r"'c� °` °��`^ a.-r?� � � � = ?'
W C � aS y T�,'�s=' � n � p �.�r � �=•n �j 7V
Q° 3 �� 4�� 0N +(m �in $ c-�c�q � �e"i 'ri ; c O Y, f �. G
Q � ,V (�jc O-c O O� �o �C 'i� '.. 'ro e�<O n...'► p N � O i G O
'L C' (1 3 ,q O `�'O C� 7 �.� � x � w.r.�v n =�^ c) t�'
� 2 m i+ o n C� o F
A ^ �p � rt w� O � �rr j (;. ,� �.'�.0 `^ � `' G ?."��.n�..%S 7 ��
S � ° i o.�°.��( a ca Q_i� °Q o o ��`o��� n`".��'= �
U+ S7 � G rG�� M �'O h` ..; '1 C J � b � - p ^ -, •:, -^ X;
41 ? O tI -� � , G
N
o U+ � 7'T�n ?b y o �� 'o''�D =,d Q 'o �n '_ ^.`� ��+
o Ai.+ o c o o c '11app%c'`= t,�� 0 3 t o a�• .c��N s^^�, -, C)
� 'U �.: o�.�S ' C� R W � ��;� "Tf '� n p i: f+ G• .
N Y � ' " (1
^ �K Q � � (1 C%'.� 7"G O � lP p u n t^. G O i)
T � o � n � o n �" ii ' �� 3 �� � c, r -, � �
cN y A v i G n .:
O O A O � A <.' <' ?•N D 7 yC1 � O p p,j"� c�.p'�
p'O G-� ro � 7 �� '� < O �C � y� c:.�, � 4 W�i .
n 7'A � fJ A — N C !:
\ `0 6 `� o � i ?� t/�o "•'u o n `y '�,. �;
oy-o� "' B� ^ '� �-v o '"o. �•`T' ,� c� /`'
c N N' _ � .. '/
� ' � C Q = J � /''//
P.Ci �i ' , � •.
.-� 3 ° � a �.
R �:] 7 n ,{ : /
G:SO V /,
V�' ��/
/'�•
. �/''�
�
////�
/�'-
. /�