HomeMy WebLinkAbout1690A (10) �,:O4KER5'CO�.!�iNSATIONDECIARATIDN APPLICATION FQR PLUMBING PERMIT L.o��Z�� �
• I hr.•rby ali�rm iF.at I hove a cartifimtc af consrni io sell ��,��q
insurr,or a cerl�fica•e ol V�orkers'Comp=nsat�on Insurnnce, CE 817�REV.IO�AI) '�����
er o cvrtifiad copy�hereo(�Se.c.38:10,Lob.C.) � �
� n(� � �� ` COUNTY OF LOS ANGElES BUILDING AND SAFETY
P❑ol�icyNo.�j��' +►_j_Compony ��(�..�C\.11�d .
Certif�ed copy is hereby(urnish=d. '
^' fC3APPLIUNTTOFiLLIN(FDiyTCRiVf'E� tiUILDING�� � 5�-,1ves Cr�.
N Ceriified cepy is(iled wiih thn cou��y build�n9 inspet• �CDa[SS
r" tion depar!mnN. NU.'ARFB fIXTURE CR ITEM (P FFE
(] �� �� � LOCALITY
Dale ���Q_,ApplicaM�\G.�l�'.�'��I-h� W47FRCLOSCT � -
�:EncEST
CERTIFICATE OF EXEMPTION FROM WORKERS' � 9ATHTu6 CROSS ST. ��` I_L
COMPENSATION IVSURANCE p�,•,•�'�q� � � C '��
(Thl��sctien n��d no�b�complefed if ths work levolvad 6y 2 ��'DV�FR � _ Y'h\�
tha permif 1�For on�hundr�d doilors(SI00)or Isst.) 5 LAVATO4V MAit _A J P
� AD�RFSS�`
I cr.ni(y ihai in thr.perfnrmant�of rt•e work fn�wh;ch ihis
ermi�is issued,I shnll no�Pm In o�� S�'�K b _" ��TY � S 2.��
P A Y Y P'rson in ony m�nner � 7
so as to becomr,subject to the Wr.rkers'Comprns��ion laws. } p;SH'1;ASHFR
CONiRACTO 1
.� ,
Do!e. Applimm } CIOiHESVJASi+IR
'� ACCRE55��
NOTICE TO APPUCANT: If, afler mokin� !his CnnYltete of � �
1' mplicn, yo� sho�ld be.:ome subjecf Io !he Workeri Swi,w1�P:G(�OpLREfFPTOR �-� r
pe.�sa��on p.o�Is�ons oF ehe La6cr Cede,yo�i musl ferth- ��T'iC\J Q.rS P r. I^i�1�1� ZZ��r
with comply wdh svth p•ovmions or �his pe�mi�sholl be � �^�`'"��coivr,i�qcycrcyi STniE t /+ 2 �n
dxemed r�vo4ed. ` Wnt[R HEAtFR IICCN$E NO. �4��, CLn55 l..J
IICENSED CONTRACTORS DECIARATION ~ CiSiA'CT h�. PR FSSE[7 Bv
I he�ehyoif�rm+ho�I orn I�cansed under prcvlsions of Chop!er 9 � Ge�55v5TE!H CuiiEiS b � 1 �� n
(ccmmen:�ng wifh Sec��on 7000)of D�vision 3 0l ihe Business OUilCT50VER � ����`�
ond P.efess�ons Code,a�d my I�:anse�s in full force ond ewect. 5 ari SvSiEM Fiuni � VALIOATION
� }
L�cense NumEer"'� `1� I L\ tic.Clnss��Q_ �ATE O
Con�.nc�or�`\T(a�Pf\+B`.3 Da�e�V� FINAI (�.
BY �
I � I ori e.empi�n�er Sec. 0
� B.BP.C.for Ihis reason W
Plan check fee ► p..
Date: P��.MSINC FiRMIT ISSl11NG FEE S 10 Z
Sign�'ure
TOTAL FEE 1, �
Plan check opplicam
$INGIF FAMILY
HO:".E OVlNER-6UIlCFR DECLARnTIO:J Nome
� "•ereby olfi�m iFni l ar�r.xr,mp�from thrz Conao:�or's l�censr.
�[e•!Fe fo!Icwiry rcr.scn(ce:!ion 7C71.5. Busir.ess ond Fdd.ess '�,� (.Q,(��
� ofessions Code�: C�ty Trl.No. � „ � � � �J
❑ 1,az owner of th�prcper�y,will do thr.work nnd rhn
shucture is no�in!ended or o?I�red fer sal� (Sr.ction , � t � � C.:Q
70a4,Busin�ss ond Prof�ssions Code J.
I :ONSTRUCTION IENDING AGEPJCY • " � � %.J Q T�
} I here.by nHirm�ho��hPre is a corsiruc�ion IPndinq o�ency fo� E�,G��'�6
' ihe pe�formancc of th�wcrk tcr which this permit is issur.d
(Set.3097,Civ.C.).
{ Len�er's Nome
I (r.nder'sAdd•�ss
I ccrnFy ihr.l I hovr.rc^d�h�s cnd+�a��o�a�d s�n�^t6at thc ►
r.bovc inlc•moiion is m•r�ct.I o�rrtrt lo comply wir4 0ll Couniy �
a�d�nonces ord$In�a lows regulotinq Plumb�nn,ond hereby
owho.irc�en�esen•a�ives of rh�s Cooniy�o�n�rr upon ihc
obov=�mr.nhened p.r.perty for ins,^.rction pu•nCSes.
p SEE REVERSE FOR E%PLANATORY LANGUAGE
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