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HomeMy WebLinkAbout1695A . WCRKERS'CO.M.FENSATIpNCECIARATiON APPLICATION FOR PLUMBING PERMIT�'<�2`-� � ' I hereby offirm thoi I hn�e�<e•�ificoir of ccnsr.nt to self ��qy�,�� � �� insure!,or o[ertifica'r of Workers'Com�?nsalien Insur�nce, CE AI7(REV.iO�Hi) or o ceri�(�ed copy thereof(S�c.9800,lob.C.� � COUNTY OF�OS ANGELES BUILDING AND SAFETY ��� P❑olicy No.�L�.CcmPanY�� . � . . Certil�eJ copy is hereby furnisl+ed. �CRl.F7lIC�NTTOFI�(IN�PA'NTGRTYPC) e11���'2 y3$ S�, IVe. Cb1.�r ��Ce�1�f�ed copy is filyd wiili the coun!y 6uilding inspec- �CCRE55 �,ondepor�mpn�. NUMBER FI%TURFORITEM ? FFE �afLiT � Da�e �+'�r� APPlicant�lc�Oe�=�V•1 WATFRClCSET -� hEnPEST I � 1 CERTIFICATE OF E%E.MPTION FROM WORKERS' Pa:ti TUd ` C4055 ST.Lt7 h . ,J �J , COMPFNSATION INSURANCE � ' � 5fi0'+Vi2 OYJNi�R (Thls t�clton n��d no1 b�compl�l�d II fh�vroAc involv�d by �,Aii fh�p�rmit is For ono hundrod dollan(5100)or last.) IAVATCRv � � ACDRE55 I rertify eho�in�hr parformanco of�he wo�k(o.which�ti�, �n pe+mit is issued,I shcll not empl�y ony An•son in�ny mnnner � SiNK � CiTr� p i . 2'Z• SO OS�O 6P.COmp SUh�PCi 10 fhP W�rkers'Co�r.pensaiion laws. � DISHN'AyiER b .� COViRA�TO � Dote Appli[onl ` CLOTHiS WASHfR � . NOTICE TO APPLICANT: Ii, after moking �his Cerlifico�e of �.CDRE55 � m �ion, � $WIM,MiYGPOOIRECEPTOR p you shouid become sub"ec1 io thr Workers' � :�mcenso�ion provis�ors of 1he Lakar Code,vou musl forlh- l•wYS�R:�iKLE'wSY$TE�41 CIT � (`�.` ,r 1 wi+h comply wi!h such provisions or ihis permir sholl b^ Sin1E ~��C dsem9d rBvokBd. WATFR HEATE4 f LICENSE Np. CLASS LICENSED CONTRACTO45 DfCIARATION C�S1e�Ci!�O Q1�(�CESSEO 9V I hereby offnm thol I am licensed undar p•ovisions oF Chap�er 9 �pS SvSiFm OUitEiS / �M1 hf� _\\ ^- � (commencing wiih SeUion 70pp)of D�visicn 3 01�he Bus�ness OUilET50vER �� ����1��h'x and Professiors Code,and my license is in full force and wHec�. 5 DER SvSTFM FINAL ��, VALIDATION y: WT,1 t Y�Lf /�-�� DATE ��/ .i p.� litener.Number {(L�"� l�c.Class_S.c_2k1__ p t� � � � � Q� FINAL �g� � U Controc�or��P r W SShCDa•e -�5��^S._ AY (OvvV � � O I om eKempl undar Spc. B.BP.C.for Ihis rensnn � 1'.1 6 4.5 A n. Plan check fee ► Da�e: � Signa�ure PLUMB�NG PERMIT ISSUING FEE 5 � ..y a . �j Z TOTAI FFE � I • � 1:O.:i O Plan check oppl�coni SINGLE F:,h'JLY e ,a � �" ";;j(j- � HOME O`NNER�BU'LDE4 DECLARATIDN Nnr�r � reby oHirm�Fa�I e�n�.=m^t frem�ti�Cen!�acroi s Licens� p V�.�.e,5 ��„.�—�j� �for tne follow�ng.eason(Section 7031.5, 8usin=ss ond �ofessions Code�� �ity Tel.No. ❑ I,az owr.rr of Ih�prope.rty,will do ihe work and the � a ,_, ���,�, ; snucture is not in�ended or offered for sole(SeUion , � 70d�,8usiness nnd Professions Code). U'�?li l, ���J :Ot�STRUCTION LEND�NG AGENCY I hereby nfflrm iha�ttir.re is a construc�ion lendinq ogency(or i��;C- _�� ttie performante o(Ihe wo.k lor which Ihis p=.mi1 is issued �Sec.3097,Civ.C.�. Lender's N�me. lender's Add•xss I cer5fy thol I hove ro��ihis o,:plka�ion ond s�are Ihot rh� ► abeve inle�malion is corrptt.I n�•e��o comply wi!h oll Coun'y crdinances e�d S�n�e lo.�s requ�a��ng Plumb�nq,nnd he.eby ouihorize repre=�ntn!ives ef this Co�nly lo enlrr upo�Ihr. ebove�mentionnd(�reperfy fer inc;.rcf�on�urpos�s. 0 r SEE REVERSE FOR EXPIANATORY LANGUAGE � \ �—�.� ��4, S�qnct�� ol�er .irc Dntn C '" I � � C? �� n "` U o• �' C,Jt, 'p � N � � t, T tr ? . �' l ,-' � •y' Y, f I• ',• rW 7' v U y� � � �t„ �� 6� G : Q i,�� 1 U � � i:? �� y • - � ? "J• a' � T}f �` ?. � � �� r xi U :� N l), � �. �' '� O . r 1�\ �� '� � n ' 1 � � n, •� , ` T w l n �,1 N � � io��a � `�� \ � ' . ;v�` � J .�� ` ,: • � �o� N ' ' `�+ �\NC n� (� t , � � �a Q ' C � �'� N . . � , a N -- \ , \ � ` . , Z� �� �., � ' O . 13 N �� V l 1 ` ,� �, \ �f � � � fi y� � IC N ��� �• � � N a ..,o a +� � � ' n ts G'a w � ' '^p �, N r p y,` O 7 . 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