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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 ()^Z�^ �� Siqnm� c1 r�ue� Da�e G G� �j 7. s ' � i' �- m w � � U ;r � <;� N , ; J� : �4 n. 1: � :�= :i . :J y `� �;. ? 1, I `� G �: i; . �U. p �' `^ �.t `'' [' 7 . y�` ? 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