HomeMy WebLinkAbout1306A '"°"�RS-`°""°E"�„'°"°"`"R""°" APPLICATIQ,rN �OR PLUMBING PERMIT � ;
I hereby offirm rhpr I hov¢a cer�ifimre of consenf ro self �y�y��
� �naure,oro ce�+l�cafe oi Workers'Compenwrion Insurance, �f et7�xfv.i0%Bi)
or o ttHified copy thmeof Sec.380q[,+lAdb.C.) ` COUNTY OF LOS ANGElES BUILDING ANb SAFETY
Q�Y��Y-i=3-l�pony rY1��1��..7 � �
� Cartified ccDr i�hernM lur�nhed, eU1t0a1G L
I ❑ iOR AVOIICANT i0 FIIL IN IPRttVT OR T`!PF� i
Cerufied copy is filed wi�h�be couny building i�npec• UppR[SS ��, , S'['
�ion deponmenl. (� NUMBkR fIXTURE OY ITFM (p fFE �
IDara�_Appiisam r��1�,�Iu�,�;�ug 3 WR1ER CLOSFT � �ocatnr �1 (Y1
I CER7IFICAIE OF EXEMPTION FRqM 4NORKER9' �/ Bnn+Tue �i � ��sr. ,
COMPEfy$ATION INSURANCF �.R �W�j� Z L�m�
(Thl���cflon n�.d nef bs eomplN�d It th�wvrk Imrolr�d by ��
th�p��nl�b for on�hvndrad dotlon(Z100)or la�s.} tqvqiOkr Z, � �� s, �f�,
I tenity�hn�in M1e perfamance of the work fw�rhich rh�s
permn�s issupd,I ahal!qat ampfoy anv�erson in any munner � � � c�fr �.+,p.
so o��o become subjec�ro rAe Wo�ker� Compenwe�on lows. � �yqyyq�ER � j
CON/AACiOR D�
�fe a�,�Ko�� «m�s w� 6 .� ,
NOTtCF t0 APPLICAM: 1f, after making ihie Cerniiicpte of 5W����E�� ��u � E� C '
1�tror+, rw should beeome wbjxr ro rfie Wotkers' ' ,
bppnitrtion pev�ifrorta Ct Ihe LoDor Cq/e,you m�n�fwfh- uyyµ�NKIER SIvS� cnr Z. �.ryp,/�- �y
wieb 4pmPly w��h �uch prorisions m thy pprmit ;hall be _ fA�C7•.
deemsd•ervked. s►nn uc.
WATERHEATFR � Il��ISFNO. y/�Sy C43 �'
uc�s�n cpNtRnavxs o�c�aRr+T�on
I hT��!Affum dpt I om lite eb urde�Pro��aions of Choptr 9 GAS svSiFM QyrtErS /_ �06i¢KT Np. pBp�qBY i
(comelroPemy wtlh Saceion�1 oi b►.rsron�oF�he Bus�nesa p�,E�pyEp �y L� �
ont!'P,ofeasiqqCqde,and mY IiSDroe i�in full tarce und etfecl. 3 ffN St�ETEM • Y '
�f /�.��� FINAL VAL /�TlON d
L�censeNumba���f�� �ic.Gmt�"-,..�_ OA1E ���/p� V :
(� ` FINAL fi'
Contrurtor��. �'7G/hOl��e BY �4.� 0 �
❑ i am axe^�Ct�mdm Sec. W �
6
8.6P.C.fa�hia r�oyon plpn chgck fiea � 2 �
Dure�
WUMBING PERMIT 1$SUING FEE E �
QignaW.e '
iOTAi ffF � $� �"'r!f'�
PIpI1 Fh0(�t Op�'IIKOn� ' h • • n • .�
SINC�IE FAMIIV • •
NOME O�MNER$Ut�OEN DKWtAT10N Name I • �•�'!-;';1� •
'� jeby affi.m rhw I om e:emO�f.om ehe Cono-acear's l�eense ,q��ees • n . . ,.,.`. '
fa�he loilow:np reason ISectian 7p31.5.Busi�e»o� �` :--•'
,b�otmsioro Code): CirY Te{.No. �
❑ , i,f.I c'^�� ,
I,as owner of�he prppany,wNl do tba work ond�he
tlrucrufe n not intended or offe.ed fa sale(Seetion ,
7Ws.Bus�ness o�Rafeesio�s Code�.
CONSTttUC710N�ENDING AGENCY �
I Aereby affirm�hot there is o coMrtuc�ion lendmg agen�y for .
��+e pprformanee ai�he war4 fa which lhi�permi+n iswed ,
(Sec.7047,Cir.C.J.
Lsndm'�Name
I
lende:a Addreas
�cm+dy�hai i ho�a reed�h�s aPO��Co�ion and slafe IhQI rAo �
obove ir�frnmonon Is correcl.I agrae 10 comply wi�h oll Cqunty
a
ondmonce�and S�ab Iovre re9ulm�ng Pl�mbirg,or�d AerebY .
authorize�epre�t•ntarivea oi th�s Cuunry ro en�er upon�he
obo e.menhO�ed(xope��y Fw in6pecl�on purposq.
. � SEE REVfRSE FOR EXPLANAtORY LANGUAGE ,
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