HomeMy WebLinkAbout1305A WORKERS'COMPENSATION OECL4RATIDN qppLICATION FOR PLUMBIfVG PERMIt � ;
I hereay offirm�ha�I ha�e o ce���fi�o�e oi conunr ro self �yq�7q
insuro,or Q ce�nHw�e ot Wake�s'Compenwtion In;pmnce, CE BU(RFV.10i81� �
oc o certlhy,i copy there�of�vSecg.3800,lab.C.) COUN?Y OF LOS pNGELES BUILDING AND SAFETY �
Pplicy No.�{AmPcnY Fz_r.t�--'�c-S ��� � �V. .
QCsnihed copy is herebY h+rnished. eunDING �w
❑ Fpp APPI.ICANT i0 FILI M(R1MT OR TYDE) A�5 � � -� .
Cen�lietl copy is filed w�th�he coumy building irepeo- ,
non epartmant. / NIIN�BEP f�7RURE0N11TFM � f4E �«ultv r �
Da1Q���,�L.� M K+d�C"'�C�Ih�1N� WAiEAC1.O5ET /O NEAREST n'�mONc�. ` i
Aad+w
� GEBTIFI('AIE OF EXPMPf10N FApM WORIQlt3' �.. BA7H TUB � �RO�ST' .
OQMPENSATION INSURANC� g��R OWNER � e`
i
(ih.6��ctlan nNd not M mmpl�t�d R th�work Imrolr�d by
fh�p�rmtl ls to�on�hondnd dollan(SI00)or lan,) avnrOpv �, � .pp�5� � (' �
I certJp that�n�he performance of�he work fa wbich ih�s
permit g ipVp�1,I shail npt emploY onY P��n in any rt�nner � � CI .NR
�o a�ro bocane wbion�o�ea waken•Co�hPorrsC�Laws. Di5MWA5HEN 11 �
cor�na+ � � . n•
Duie. _�pplican� ClOT1rtS WASHEY ��
NOTICE TO 0.4RICAM: It, dher mdkirp�his Certiflop�e of 5'awWUNG ao0i¢[#vroR
`�pTOn, ypu should became mbjec� �o �he Waken' Giv lEL NO. �
. Jpemaaan p[wisirnaa af 1he lebvf Godeo yo�mVu tonh- �py�y ypq�„ryy,�sniF�t �
w�ll�igmply with �uch pro�isions or thii pe!mil fhqll 6e ST��� �� �—�
deemedre+vked. � WAfEA1¢A1ER
U�CONrRAC'�R9 OEQAR�4MJN aSTaKf oROcaS�ar '
�nmebl aAfx,n��am Iica�ad ueda aa��s�ons ai�hapter 9 Gat srsiFM � amErs �� .
IcQirmieneing wuh Senlon 700tl)oi bi.nion 3 of Me BNnness W�IEnOVEa . Y
an�fProlriti�n}Cyda,and nry liesnse is inf�rll forceand.lffect. 5 PER S'S7F1H FNAL V LIdAT10N 6 �
Lcieme�ber 7,y 3��y,�� C pAiE ��O �tr �
c.Gass�
t� [� HNAL �
Wnlroctw��FG.��l-ttfn�y�poro]..��� Bv o .
o "
+am exemp��mder Sec. 6 �
N
Q.SP.C.fa�his reaso� Pfan ch.eek fee � Z �
Oo�e: � .,.�,1 �
PIUMBING PERMIT ISSUING FEE 5 V v
Siqrq�we . TOTAi ffE .� � •:`�`'�. '
P1an chxi appl�conl .. • • • • „
$INGIE FpMIIY
MOME UWNER-BUIIDFR OECI1IRAT�ON Nama 1 • •r%u ::i� .
'' �affh'm Ma�I pm a.smpf hom�he Contractor's Lied�e - �.r
ao-�ha followi�rep+on�Sercrion 7031.5,Businen and �reas � + . �i. ;�,i;�.:
�Prur�fiO�f CAde): [ify iel.No.
QI.as awner of�he properry,wNl do�he wvrk arny�he � l�i�1 - �.•/ .
sm,erure h�+i�nm�ded or offered for apie(Secr:on , .
7040,Busines�ond Professiom Code). '
CONSTRUCTION lEND1NG AGENCV
I i�rreyq ofkrm thm�here�f o consnuetion lending age,ny fa
�he per�am�anro o��he worM fa which+hie pormi�i�iaued
ISec.3097.Gv.C.1. .
Lender i Name – - .
lander e A�drets
1 cemfy�ha�I hove�read ihis oppl�ca�ion and sro�e 1ho��he . �
above i�Qrm�ion b cortect.1 agroe�o comply with all Cpunry
ortlma�tes an9 Stote lowa regula��ng Plumbing,ond 1[ereby �
authprija�aprasen�o�i.es ol�h�s Gwn�y ro enter vqOn �he
abor9mentloned prop! y for inspec�ivn purpof0 SEE REVERSE FOR EXPLANATORY LANGUqGE
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