HomeMy WebLinkAbout1308A WORKERS-�M�N�T�oNOE��,RAT�oN � qpPLICATION F4R PLUMBIN.G PERMIT � �;
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I hereby offirm rhat 1 hove o cartiticata of coment ro eeli �ypyp�q
� Insu.e,or c cenifimre of Wakers Compen;a�ion Inaurapce, eE BN�aEv.�or8i� � - � . �
�o.a cenlfied copy fhereqf Sec.38pQ Lob.C.) � � �
�� ��rm�C� COUNTY OF COS ANGElES BUILDING AND SAFETY
Policy No. pony � � . � '•� - � ;
� CeNified eopy is fiereby fvrni�hed. � ;
WR APPl1UM TO FttL 1M(PRIM OR TVPE) Bnlll��� ' . . .
� Cenlfied mpy is filed wi�h rhe counry bui�ding impec• Nu�� f�E�i� � � `�1tt � M • � 1
tio deportmem. R
Dpte n��Appli�ont�^��•plt,tmi�nr� WA1ERClOSEi . (�j}; �� .
CERTffKATE OF IXEMPf10N FltOM VYORKERS'- I/ BATM TUB _. .
COMPENSAiION INSURANCE ��R �R C Z���r �fl'1, I
(Thl�sacflon ns�d nef b�mmplat�d if ths work Involved 6y . �
th�p�rmit N For oe�hund+�d dallan(SIOOlor lass.) �qvq�p� pZ A�pp�� ��(` {� . �
I cen�ly�ha�in�he performanea of the work fo.whicb th�a
permit is isyued.I shP1�not @mptoy any�erson in tmy mo�ner SINK (/j3 CITV TEL.NO.�'�..
— ' so m to become subject ro fhe Workeri Compensotian Laws. / / . �
orsFlwasrlElt �p CANTRACTOR�] '�
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Dele °PPiimM CIOTHES WASMER AWRE55 L.. C :
N0110E TO APPLiCANT: If, ntier mdking�hn Certit��nte of �� '
kmp+ron, you shwld become s�bjec� to �he Worksrs S���P��°�� ���r m,rp !
�y�bmpensallon provisions o4 fhe labw Cpda,ypu must forth- uNm SPRw�tE�SySTfM �� - I
wi�h comply wieh aVch Drovisio�s w fhis�pe.mit shaU 6e � 5rA7E � 1K.
deemed revoked. ww7flt r�E4fER O�7 U��. �, y �� �V '
UCENSm COMRACfQRS DEC1ARAilON f rnstrticr r�� vRocEsSEu er
Iherobyaffirmlhati.amlicemedundprprw.isicr�ot�opia9 �5�� �� �e 1
(cpmmencing wAh Sectfon 700p)qf DMsion 3 p4 fhe$�Inass puREtS;Ov¢R . T
andProfeniom�Code,aridmylisemabintuTi-fprceondeffect. •SPERSv57EM FINAI V fDATiaN �' .
�14 37'1�1 C-3G, oA,� i� �'� �
L�cpme Number�!ic.Claes . '
f� FINAL OC I
COnhnC10!�-�+Q,b.l�trl��p0/Q�_ . 8V 1� �
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�om exempt under Sea . . 6
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s.sr.c.��n��re�o� Pinn chesk tep , _ .
" �}�� PIUMBING PERMIT 155U1NG FEE S lO �
s�9mwrc -- - �1 3 Q 8 A '
rornt� SD';
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vta�tne�m,a��mm ;
sir��Fannur _ #• • • • •5
HOME pWNFR-8VIl0ER D�tARATIQN Nome � �
`preby affirm thm I am exempi from�ha�onrtonrn's licenne 1 • •9 6 5� 1
�,. Jr fw rhe foilowing reason�Sacrian 7031.5,BnNnesa and �d� � � l�r �= i
r.�r��o�s code - .'. .9 ,:G�
� Ciry ` Tel.No. �
❑ I,ay owner of the propeAy,will do Yhe work ond the , ,► a Z 1 2—8 5 j��
struc�v.e u+rof inronded or offerad fa snle(SeNion � . � !
7044,B�siness cnd Profauiom Code). .
CONSTRUCTION IENDING AGENCV . . � �
1 hereby affirm thaf thera is a conshucrion lending agency for . � ;
the pertormance oi tha work fw whicA this permir ie rtsued . . . - - �
(5ec.3097,Cir.C.). �
A
Lender's Name �
Lender's Addreu
I cen�fy that I hava reod fhis applicotion and sta�e thel the , �
above information�s conecf.I ogree ro comply w��h all Oounty
ordinances and Slate laws reguleting%umbing,and hf.teby �
authorize represenlotives of-tbie Counq�o enter upon�he � � � �. , � � ,
a6 e-menHoned pro erry fa inspecfion pur � � � ,
��/ � � SEE REVERSE FOR EXPLANATORY LqNGUAGE .�
�gnatura of Ver e te ' � - � � � � �' �
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