HomeMy WebLinkAbout1306A (7) '"°"�RS-`°""°E"�,T'°"°"`"R""°" � APPLICATIQ,rN �OR PLUMBING PERMIT � ;
I hereby affirm rhpr I hove o ccrlifimre of consena ro se�f �y�y��
�naure,oro ce�+��cafe oi Workers'Compenearion Insurance, �f et7�xfv.i0%Bi)
or o cehified�copy thmeof Sec.380q�,+(Apb.C.) L COUNTY OF LOS ANGEIES BUILDING ANb SAFETY
QcY�plY1v���pony rY1��1��.-7 � �
� f�rtified copy i�hernby fur�ished.
I ❑ iOR AVRICANT i0 FIIL IN IPRiN70R T`IPF� e��� L i
Cert�fied copy is filsd wi�h�be couny buiYding i�npen UppRESS ��, , S'['
�ion deponmenl. D NUMBkR FIXTURE OY ITFM (p fEE �
I �ara�_a�NGa�+,•�•�,�Iu�,�;Ng 3 WR1ER CLOSFT � �ocunr �1 (Yi
I CER7IFICAIE OF EXEMPTION FROM 4VORKER9' �/ Bnn+Tue Z � ��sr. ,
CAMPENSATIpN INSURANCE �,R �'N��j '� L`m,
(Thl���cflon n�.d nef bs eompbt�d It th�arvrk Imrolwd by
th�p��ni�b for on�hvndrad dollon(Z100)or la�s.} tqvnrorer Z, W ��' s, �f�
I tenity dn�in M�e perfamance of the wark for�rhith rh�s
parmA�s iu,ipl�,I ahall qar amp(oy anv�erson in any manner � � � clrr �.pp.
w o��o become�ubiec+ro rhe Wo�ken Compensoe�on lows. J �y�w�ER � I
� CON18ACiOR D•
�fe „�: tr��Ko�� «m�sW� 6 .� ,
NOTtCF�D APPLtCAM: if, after making ihie Certifi�cpte of Sw�MMiNG ci00t RECEviOR A�� � �� t�• �
1�tror+, rw should beeome wbjxr ro rfie Wotkers' ' ,
hppniqtion ptvviarorta Ct/he LoDor COLIO.you mui/forfh- Nyyµg�NKIER SYSrFx cnr � �.Hp,��y
wieb 4pmPly wii� �uch prorisions m thi�pprmit ;hall be - .
deemL�•svv_�d. nA7F uC. .
W ATFP HEATER � L1��ISF ND. p/�y C'3 .
uc�s�n coNnwavxs oEc�aR�+T�on
I tiA[D�!Affum rlpt 1 om lise�sed V+dO�Pro��aions of CRqptr 9 GAS SvSiFM OyitEfS /_ �Q67¢I[T Np. pgp�q6Y i
(comcAepang wnh Sacnon 7I�b01 oi�rsron�oF�he Businesa p��pyEp �y G� �
ont!'P,ofeasipqCqQe,and mY IqDroe i�in full tarce und e{fecl. 3 ffN 59ETFiN • Y �
LicenseNumbe.��r�7�� � Oa�� �/�/p`_ VAL! KTlON � ;
�ic.Gmt w V :
Contrcrlor��. �"'1G1►501AY�L,�e !/� BY� �4.� 0 i
❑ � .
I am e:empt under Sec. W �
6
8.6P.C.fa�hia r�uyon P�O�[h@C�c f69 � Z �
Onre�
WUMBING PERMIT 1$SUING FEE E �
�ignaW.e '
iOTAI fEf � �� '.(i f,;; .
PIpI1 FhD(�t OpPIKOnf ' j� • • n • .�
S��f����/ • .
����R$V���A��{�TpN HGT7 � � ��''�-�:�j •
'� jeby af4i.m rhpi I om e:dmO�f.om ehe Cono-acern`s l�eense Addrees • n .C:; (:�.,.�. '
fa�he loilow:np reason ISectian 7p31,5.Busi�e»o�
,hrMnsion�Code):
❑ CirY Tel.No. �f.i !-:�� I
�,as owner of�he propany,w�ll do tl�e work ond�he
tTucrufe n not intended or offp.ad ia sale(Se[tion ,
7pqs.Bus�ness ond Rofeesio�s Code�.
CONSTttUC710N�ENpING AGENCY �
I Aereby affirm�hat the.e is o coMtruc�ion lendmg agen�y for .
�he pprfonnvnee ai�he war4 fa which Ihi�perm�+n bwed ,
(Sec.7047,Cir.C.).
Lendm'�Name
I
Lende:a Addreas
�cere�iy�ha�I hp„e reed�his aaPi�co��on and smte�hp�iAe ►
obove ir�frnmanon Is correci.I agree ro comply wi�h all Cpunry
a
adinonces a�S�a�e I�.e regulm�nq Plvmbirg,a+�d Aereby �
authorize�epreYlntarirea oi th�s Cuunry ro en�er upon�he
obo ernenho�ed�xope��y Fw in6pec��on purposq.
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