HomeMy WebLinkAbout1693A I WORKERS'COM.PENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �u�-�-23 � �
I he�eby alfi�m ttiai I f+ave a cen�f�cm.r of consrnt io sell �bp,y�,�q
ins�re.,or o c=rt�(�cn�e.ef Workers'Comprrsetion Insuro�ce, fE Bi�(REV.10�81� �`�h�
e.n ce���Ned coPy�he�ecf(Sec.3800,lab.C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑ol��cy No�g q-�1} Com,ony�'(��� , ,
Cert�f�ed cepy is he•eby}�rnished.
FO4 APPL�C�NT TO F!ll IY(�R'NT OR T�PE) BU�LDING
�,�i'� Cert�Red moy�s filed w�ih the counry bullding inapeo- �CDRFSS � �,l
licndeportment. NUMBER FIXTUREORITEM �d FE�
1__ \ LOCALITY
�o�e�_ApplicoN� `n�+'�x�yh( � WATfRCLOSET � KEAREST `
CERTIFICATE OF EXEMPTION FROM WORKERS' 2, BATH T�A `
CROSS ST. O� C \ �1.�
COMPENSATION INSURANCE � �
� SHO'NFR \ CWNER \�
(This��dlon n��d nof h�complN�d il fh�werh Invelr�d 6y Mq�� \
th�permlt is lor on�hundnd dollon(SI00)or In�.) � tqVaTOav / AD�RESS
I cen�fy�hai in the perlormonce ol ihe work For which this � $INK CiiY �^
permil is issued,I shall nol employ ony parsan in ony monner - S
so as ro become subject+o rhe Workers'Compensa��on Laws. 1 D'Y+iKASHER J � 1 \
� CCNiRACTOR ,�
Da+e Applicanl � CLOTHFSWASHER � ,�DDRESS
NOTICE TO APPLICANT: If, aftar moking �his Cenifico�e eF
�emp�ion, you should become subjecl to !he Workers' � SWiMM�NG POOL RF:EP70R .
rmpensar�on ov�sions oi�tie Labo.Code, ou must Fo�ih- CIT. �
with comply wirh such provisions or �his permit shall be 1°'NNS�R!NK!EQSYSiE.M SIAIE ` C.
dOOmOdrevoAed. `` WATERNEATER L�.'NSENO. � C;A$$ �
LICENSED CONTRACTORS DECLARATION C,SrR�Cr NO. raOCESSEo ar
I hereby offirm�Fq1 I am licenaed�nde�provisions of Chop�er 9 1 GAS SVSTEM CUTlfTS i �O \ �^^ �
(tommencinq wi�h Sec�ion 7000)of Division 3 oi the Business OUTlET50VE4 , �y�
and Professions Code,and my license is in full iorce and eifett. 5?ER SvSiEm FINAL VALIDATION
`��1�t �a q� DATE t 7 p},•
license Number��,p�`"1 Uc.Closs�� � p
p F FINAL U
Con�.oc�orR ` P��bhS Do�e -� 2�C�81Z BY �
� O
I pl:l BxBMFf U��P.f SPC.
B.BP.C.for this reason W
Plan check fee ► Q.
Dote: �
PLUMBING PERMIT ISSUING FEE 5 Z
I. S�qna�ure
TOTAL FEE
J
Flnn chec4 applicant
51^JGLE Fi1.M.ILY
HOME OWNER�EIU�IDER DFCIARATION Name
"•r,ryhy effirm�hor I em P�emp�frori the Contrnc!or's License q��rrss
. }r fo�14�e following rr.oson�Sec�ion 7031.5, 8usiness and
ofesslons Code): �i�y Tel.No.
❑ 1,rz ownnr of�he prc,^.�riy,w�ll do ihc wc•k a^.d!4e , �-'I f)`.%J r'1
struciure is nal interded o�oftered fnr sale(Section ' �
70dd,business and Proirtxsia�s Cede.�. . e • a•
�ONSTRUCTICN 1EN01NG AGENCY v
I hereby nNirm!ha�ihere is n cens!•utlicn le�dinq a�en_ry for �� ° � I C J Q
ihe per(o�mon�r,of�he wo.k(r,r whicf�iF�is p?rmli is�ssucd
(Sec.3097,C��.C.). ` .• � I �.:)ii::
Lend�r's Nomc
��i��-'b
Lender's Address
I cerfify Iho1 I hnve rend th�s nnp��ca'lo^a^d s�o'e thal the ,
chov!+infcrmoHon rs m�mct.I nq�en ro cemply w��h nll Counry
ord�ncnces nnd S�a�c lows.er,ulo��n9 Flumb�ng,�nd he�eF.y
au�hcnee r�nrc�en�ouves oi iti�a Counly to rtnicr upnn ihc
a6o�e-ment�oned F�ec.e ry for�nsp^u�on�urpe<ns.
� SEE REVERSE FOR EXPLANATORY IANGUAGE
`_ -Z�,�8.�
S�gnatu cf Per �.. rtc Datc
�` �
G� 'n n `c7
�, S v G
G �l O `r -> Gy �ao
' i�: i �, �: ,� �i ,i
T ' 7. .
:i 1 f� • yi i � C U% ,xl
T' < ' (;l
`^G � N ��, e,u C . �
.u� � .., � 4, �� i^
'�;�,�, p r. �
ri� � � :r N
U, - �`
S �U
. � �J�
•�,t ,� -� �� t O
\ .. r.�
� n.
� � i `\�`� � . �
\"' � `J C�
�' `t�; 7.
� ';,
. � �
� . � . � .� ��
� �.
.: ��. N
� , N,
�„ 1 C� �
�, : � �:.
O� ,� C
��
N
a� , •
�N � •
�
. \
\ \ m
\ � O
� ' V N
� N
f�
U
�+
u�
�
� �
_ � o e c � �
G S7 �= �
� �o i� -• c � � v
� O� � �� .�.. o,'O l9 C` •C
O"Q � 7 0 �n �' � p
j1��� �'� . � j � ='� ^' � p � � C
S
• 7 •�!'. T O n v � � p (4 �1^ �f1 tl y G~ � �
�N O n ,� 7
' � S 3 N O � �J G` �Cc, C G G+�n Ca'� -[ �� �(�
o �o x �.�,o o '�? 3 c � ,u
� Q II'^O C"?G^� i^ P o n C 6 O-. � N ii� :: o ?� �
Q° 3 � t9 O.3 O-N p �n O< �c�"� ,0 O n �=^ O u� � �.
\ Q O -a % o.c,� � m.,o ''� N Y v �i n o C<'� � o� o � �� �,
7 � n 'n � W�"�'O � �2. R n n. � n n tS7 '�' p G.�, � 'r... !:b 7 �
^ o . . � 3 N �o 3a.„ ^ �^ n ° a �; o �^c. .a c �. r �
f " � ^ r
< o , -� :.o s _'•'-� j �:�.
o ==°'n-o N � :� �, o � x unw � o , n
• N � � G C O � N O 'O �'!� '> C , j O _'J � ry �•Ot)•�� N4 ,•�,
� �� T� c ?� �O j U ry 7 e?i r�'. 'o ' v^ ^.� 3 %'�
� � _,� � l'J N n v N �t' � -i < d C: •O=�...:r� 7 .i =r �
7 n � .� G 7 -��.U K j f�+ f; 7 � fi v i"'� n C p .� � q l �
� cu 3� � o � 4 � Q'� � ° Q n ' ' - n
. � �.C. O n f1 ffJ-G =c. c 0 N - o N :1 r, �O O O
0 ocQ ��'� oo c^ „ o � o n � 3 N � o ^ � > >,
< a r.` � ...^_� � � � o n . _,�
. o °�° � � � � < � o `c.�, Nc-v,u � u�F
� �
' "'o n' 6 T � � ' _ -
T 3 O � ?R G T ln ci 'O!:, p �;�C •�,,�
�7 3 n � C O� O C��. ?.Ci'p - _ � i^ � .
�`�� � '" n� o ' ai'a u �'�" � ;� `,' /�•��
`=T — ' 6 �n � � q q = � �` Y /
. � U 0'" T� � tL ' /
_ .J 7 7 p N� //`//.�
fJ � � r`
R T� � ' �/
G�
'//
�'!