HomeMy WebLinkAbout1286A �aKERS-�oM�NSATioNOE��oRAr�oN APPLICATION FOR PLUMBING PERMIT �
I hereby affirm thar I hove a cert�fico�e of conaenr rp seli �ypby�q � !
insure,w o cenifica�a oi Workari Compentotion Insufpnce, CE 81�(REV.10/81) �
s
or o cerrified copy�hereof(Sec.3800,Wb.C.) � - !
�ArM�,r� COUNTY OF LOS ANGELES BUICDING AND�SAFETY
P�ol'���No�?.���0�^Y_ �� � ..• .' ;• 3� ;
CeMified copy ia he�eby furnished. BU�� �
� roa aoriKaNr ro ciu M�raiHr oa rvre) nooaas S• 2� 1
Certified copy ia filed with the co�nry building in3pec �
tion dqqM mem. A NUMBER FORURE OR rtEM � fEE ��tt '
Date__.�.�!.(.�IAPPti�ont�1G.�.1�1/11YI4�{�� WAIFRCLOSEr 2 /JIa � . . ;
CERTIFICATE OF E7CEMPTION FROM WqRKERS' f� BAiH NB �5�' t
COMPENSATION iNSURANCE �pWER pyy�p (• �LI�L°. . �� ��e
(Thls ractlon need not M wmptafad t1 th�work tnrofwd by ,�
1h�p�rmN Is!or ons handnd dellan(ST00)or I�ss.) �AVATpRV qpp�$$ i (� v �' .
�
I ceni(y iha�in�he perfotmonct+of�he wwk fw whieh�his - �
permit is iuued.!shnll ml emptoy any penon in any mqnner 51NK � (f� CIiY � 7E1.NQ.�' " -
_ so ae to become s�bjed lo Ihe Workers'Compensotion lows, a��� � � � � -
UU�GONiRACfOR � �
Oafe aM+licCnt � CIOTHES WASHER �./ �
NnTICE t0 APPlIG4NT: If, afler rtroking fhi�Cenitimfe of � A�� • i
(� pnon, you�should becoma avbl� ro fhe WQrAe� 5������ ;
.,_�pen�ation provisiona of rhe La6or Code,yar musf fonh- Cm � rEl.NO�� u,
�� V+WN SPRINKIER SYS�EM
w;� somply vrith such provisiom or ihis permi�s6all be STATE uC. /^ �
d4emed�evoked. . WATER HFATER ��. � v`� j
- . UCENSED COMRACTORS OECtARATIQN - � OISTRIGT NO. PROCESSED 8Y ,
I hercby afNrm+hqt i am licemed undar prpv�sio�auf Lk�opter9 �SVSIFM OUfIEI"' � !
(commenc�Ig with Sectipn R10p)of Diyision$nf tAe Busineas pMErSpvER . �. ;�
and Professions Cocle,and my license q m lvll forroond effec�. 5���
F�NA� /p� VAUDATION , V ;
�14 77u /+_`�� on� /�d�
��censeNumber �-1 -�ic•CIosF�Ss�-�"�,fo . � ;
FINAI 0
Cono-octor ARA.�Wmbl��qte� � � BY /�j+a.ecs.�i � ;
� I am eKempt under Sec d �
H .
8.8P.t.fw�hie aeason Pl�n check fee Z �
oafe: vuinneuuc r�amrt,ssuiN��s p � �1 �&6 A '•
Sigmlur0. � + . . 7pTAl f�E ...�� - �l�'• • • �rJ �
Plon cheek appli�ynf � • �Fy 2.J� �
SINGIF FAMILY
HOME OYVNER-BUtI DEGARATION Name �
}�by affirm�hat I om eaemp�the Controno.i Lieense . '� � �8 2 5 p�
! Jfa Hro followi�reuson(SecNon 70:l1.5.Business ond .Addresa . . . . - � 0/.� 2-�S 5
ProfeniomCode): - Liry Tet.No. '
❑ I,ae owner of the praperty,will do fha work and the � . !
slruc�uro ia nm inrended a offared fa sale(See��on . ► _ �
-71M4,6�sinesa mid Professiom Coda).
1
- CONSTRUCfIpN LENDING AGENCY . � - - � � � �
I fiereby aHirm thal�here is o conshuNion IenJing ogeney for � 1
ihe performance o4 t�e work for which�his permit i�isYued . . . . - - ]
(Sec.3097,Civ.C.). j
Lender s Name � -
Lender'a Addreu . �
I ceNify iher I hove read this applimtion and ataie fhnt rhe , . � ,
above inforrtwtion is correcl.I ogree 10 comply wirh all CQun1y . . j
wdino�xes ond Stute laws rag�lari�g Plumbing,and hemby j
outhorize rapresemati�es oi tbis CauMy to enter upon�he � � �
o ve�men�iOned prope�y for inspetlion purposes.
, � . SEE REVERSE FOR EXPLANATORY LANGUAGE :
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