HomeMy WebLinkAbout1686A (10) 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
c, c� ..
G� 3 �. V�
� r �G �� SN N ��, u
a r � �� �.
,> � m % .,� y'
T � r �. �
r L � -� �`= Y �L 'I- �G p� jO
r�� � e� i.'� '1. � :•� . .. U
��C: C� �� N iP �j �.
�,:: � � � � �^ ��
� a � � � �; x
.•,= �
`= A: N
U '� i,,
�,- Q J
r
, � �
.� r`�\� � .i1\q
n � � R'
.; `..� _ � �� c
' ��
� �
} ��� a � � �
� - � � ��
\ � F
r
N
in
� `l�
A `�
�
?O
�
�
?
��
0
A
N
. �C7
M
�
r "
n3co ie � ��
Q- O� ?n 7 � 0 N N C1.
� �� A
�,;r O�� TMuo o:s • � �s ° O
f £ � �,U � �' o �' ,5,�o _.� �r c� = ?-
�°.�v4 �°�,�p�r"O���� a� o�' �sNQw � o� = �
W C 6� o{�y T t.�j o•GW�O <<�o O �n n j �O u� f -- G
� �� @�� O.M o ' p�? 7 q
O p •0 (� O.GqO � M �CJ �� J'0o ��.4opc �� %G. �
o q '�-o . ,� �.•
4, o (1 xA " m"�-0 2 0 �� � ^ 4 A � ��''" � ' n�7 ° �
a c o .
w ^ .�p 3 £N ° 0 3 o W � o„ ,{�b a� �c s�.�y; 2 �•
�o . Nm oo � � ,, wn�.� o . C�
S h ° i o.�.�.��.( '" o.n.�� °° " � o �o � °_� 4c ;, i
J+ L7 � G �.' �� M O 'O lC ..� �1 p J b ~'O .�.. ? U a, � C:. iF)
G
f� o p p ?� C � O n C' �"'�� ' 2 p O y 'w_ �`'�' A�
U n s 6 � m N '°'o N c;,��i o 3�` � �. �' S�`"-c:�` '�,� C� .
. �[, A ' �/' � P. <+ �L•
O C�O �.� 0'< p ry-� A � • �n,n,C1 `� � C
, -�(�.c,o�' � o ~ �' ", 7'c n Q m� o� � �% �fo ^
�+ '� n � � n � o�� nr-.� ,,, 3 c, � � � .
N v � A
t1 O O It `Y� A� �' ?,h<'� 7`�' �'-� O � P,r.� C����
C� �A O £ 7 �',�n R �=c � N N C �'4 �',� .
' \ _p G `� O O � t ` � N n..!s�. O o .. ,=-„ �t`. �;
� � � � � oo c 6c °�of ;T;� c . ^.. �
a �'�c '^ °'�'� ^ � �„-v o " r 's" �
iv'• � N /'�_/
' C�Q ll� � C 4�. . N
�.� � ° e °� /
Q, �t 7 n ,t � /
` G�n U S J�.J
��.
'/��,.
/ /�
/�''
. /�