HomeMy WebLinkAbout1307A (7) 1
WORKERS•�,,�N�,T�oNOE�aRAT�oN � APPLICATION FOR PLUMBING PERMIT � ;
I hareby aff'um that I hnve o cerGficote of consanr!o self �yqyb�p -
insvre,a o caMifiwte of Wor4en'Compensarion Insvronce, Cf 8n(Rev.�Oi81) -
or o cer�ified copy th'x�7e�se�ssoo�+,t/e�b.c.) �COUNTY OF LOS ANCELES . BUILDING AND SAFETY . ;
P�o�icy No.�,LComfpany t^/"S��YIL�C.S s '. � . i
Cenified copy is hereby fumished. � Z i
OFpR ARIKNtlT TO FIU IN(PRINT OR TYPEI BA��R Zj�`7 +� �� ,
Gertified copy ia filed with the county bvildim�inspec• w"'�
rion deporlmeM. NUMBER FlxruREOR rtEM � FFE 1�tm, � i
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Dote�BiAppli�ant Y������N/�'1�� � WAiERQOSET . . NFARESt . . . i
� QtOSS S7.
CERTIFICAiE OF EXFNTPTION FROM WORKERS' enn+nB �Z. !
COMPENSATION INSURANCF ��R OriNER � 4'� �
(Th��raNion nsed not b�mmple»d if th�work Inyoipod 6� �l + :
th�p�rmN b Tor one hvndr�d dollan(5100)ar I�is.� lqVn70RY a �// a�pp�R65'�1 � ,{�� A . �
I cenify�hat in the performOnee o4�he wark fer whi4h ihis .
permit is issued,I shnll no1 emplpy any penon in any monrror SINK . � OTvC TEL'NO'�..O _
- so as to bemme��bjan ro rhe Workers Compemation tows. D��� � � ��� � ,
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Daro °PPlimnl � � QOTHFS WASHER n�DRE55 . e, ��:
NOTICF i0 APRICANT: If, afler making rhis Certtfl�te oi 5�������� �
- �mpfian, you ahouid Acteme sub"Lect ro the Wgken' ��Ty � � j
t penwtion provniwia of ihe Labor Lode,you mu;rfo.th-
with comply wit� such provisionn rn �his permit shail be �����pS�M SiA�E tlC. /�� �
deemed roroked. Wq���R � � IICFNSE NO. � CIA55 4.�� �
UCENSED CONTRACtORS DECIAI�ATIpN MSia�cr no, vkOC�SSEo ev !
- I hereby affirm tFqt I om licensad urder provieiom o.f��hop�er 9 c3Fb5 srSrEM our�ETs `O � :
[commeacirq with Sectipn 7000)of bivisiqn 3 ot the 8usiness p�n�t5Oy�R , '
ond Profeniom Code,ord m license is in II force qpd.effect. 5 FFR SvSteM � y '
l/ �jY �' ,,��� oA�� / /o VALIDATION V ;
l�cense Number Ry 7�7� �%•.dass_L'_i 3
FINAI � �
Contracror ' �, Oate�_ . BY � . V 1
W �
❑ I CT ORQTPi VIfAM SK. . . . 6 .
e.aF.c./or Mn,eascn - - - — � M ,
Plon check fee , Z '
��e� ' PIUMBING PERMIT ISSUING FEE i �
Sinn,.,...e .. 6 � �
� - . �OTQL FEE �
� P1an check applimnt �� v�'7�
SINGLE FAMIIY � � � � �
HOME ONMER-BUIIDER DECU1RA710N � Name . . �' • • • • •5
t
Jeby affirm tha�I am ezempl fiom eAe Controctoi a Uce�se - . ' � . .C(i.$Q
� I io��he following repnon(Seetion�0.i1.5,Busirroas ond �A�`°� - � ' ��' �
�I'rofeuiom Coda): � . . Cily Tal.No. � • e r 9 4,j(�� i
❑ �,as ownar of the propeny,will do rhe work ar�d the � �
sn�crure is not in�ended or offered fw sale(Setr+on , 0 7.1 2--8 5 �J
7044,Bminese ond Rofessions Code). ' �� � 1
CONSiRUCT10N IENDING AGENCY . . � - �� � I
I hereby affirm rhat thero is o construc�ion lending agen�y for �
the performunce of Ihe work for which Ihis permit is issued . . . .
(Sec.3097,Civ.C.). .
. . . � . .. . . 'i
lender's Name . �
Lendr's Address I
I cerNfy tha�I bove read this applicafion ond swta tfqf the � � � ► . .. . .. . ;
above information is corretl I agree to comply wi�h all Cq�nty '
ordinances ond Sta�e lowt reg�loling Mombing,ond hereby , �
oufhorize ropresentatire�of fhis County ro enter upon the �
abo -meNioned Pr parry for inspection purposn. . i
SEE REYERSE FOR EXPLANATORY IANGUAGE
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