HomeMy WebLinkAbout0788A (4) v,oRK��S��o"'.FE�SATIONG�CLA4ATION APPLICATION FOR PLUMBING PERMIT �
I hereby ofLrm th�� I hovr. n cerhfim'e cf mnsent�a self �ti��y�q
insorc,or o ce�i�{�m�rt r.f Wer4er5'Comparsntien Insu�ance, CE BV(REV.IOi811
c�n ca�tifi�d cc;4y'Frr�r.f(Src 38..M.,Lr.b.C.) COUNTV OF LOS ANGElES BWLOING AND SAFETY
P�ol�icy No. Cnmpnny
Cerii(�ed cc�y is herrhy fu���sFed.
Dre�nr.:�ic•�hTTOF�IIIYj�'414TCRTY;E) BL'l�".G / (^��.,�� u
C^r�ified ceny is 6!ed wiih thA ccunry buil�in3�nype[- AbDFrSS ( a)
��on depar�meni, r.J!•tiFR FI%IL'p:OR ITf11 (t FF'_ �
L0.ALtiY yf_ .
'NATFRCLOSFT � �''
Da�e ��IiCanl N�AG�ST
CERT4FICATE OF EXE.NPTICN FRO.M VNORKERS' 9�T�i 7U9 CpOSS ST.
COMPCNSATION INSUPANCE p•;,.;rq /� / / /_ �
(This��tlien nNd nof b�compl�t�d il Ih�werk Inrolv�d 6y SHO':TR �.� K —�
fb� �rmlt fa for on�hundr�d dellara 5100 or I�s�. M.RR
v ( ) 1 in.vnrcxr ao��ess L 1
I cenify IF�I in I�r,perforr�er.�e of ihe work fe�wh�ch ih�s �
P8lTil i5�SS11Pf��I Sh.^.II I1C!CTFI�Y C'1Y()CIS�'1 III OlIY I^p^^^� S�h�K CIIY i;�.N�J. �t.��
V
so as to become:uhjrc�io the Werkr.rs'Cemprt�safien laws. DiSM'fr�'.��ER
, ce�.TauToe �e�/
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�L� Dale�E���LL�—�oFlimm� ClOifr•S�YASHER !.D^�r55
� NOTIC TO TPLICANT: If, nNor mok;�q+his Cx�nfico� 01 �, ,�„�„ �
Exemo��on, you shnuld hemne svbject lo Ihe Wcrke.s' -�� .•����'IRECE�ICR
Compn�so�ion provis�r.rs oF ttie loh�r Co�e,you m�sl forih• CITY if: N�.
w��h romply wifh such prnvisions or tl:is permil s��all En ���'��y�'Pp���KLERSVSiC.h1 STATC �i�,
dvemed�evcked. \•:A?FR!�FA?FR IKEnSC np CIn55
LICCNSfO CC�JTRACTC25 CCCLARAiICN C:Si."'CT n0� ('WOCESSCD P.v
I Fereby aHirm!f:o�I cri Ilcenced undrtr prcvisi�ns c�Choc'^•9 ! Gn5 SY9C4t CUTLCTS p� v
(cemmpnci�g w�eh$ecl�nn 7000)of Diviseen 3 r,�f the Business CUT1E150vER r
a�d P�oiessfons Cale,and my i�cense Is in full for�e o�d wHeci. 5 afR SVST[x FI'JPL _ �,�//,'
DhTE /�� ' vA��DAT10N �
licanse Number Lic.C�nss �
� FRlnL '� („)
Con�ro:�cr ��I� BY O
❑ I om e.empl und�r Se:. `r U
B.BP.C.fcr this recson w
Pion check fee �
Or.�e: F�UMHING PERMIT ISSUI!`G FEE S U Z
Signol�rc �
TOTAL FEE �G S ; O'�R s�a
F'o�d•cck ocr•I�cr.m �—� o � C
SI^JGLE FA:•.ILY •� � �J
I�OME O'1:'`F4�P. ! R � '�
U!C: �.CL�pATICN Namn I . . , / S�
I Fpf9bY n�Ii�RI ih(�t I(im pxpT.(�1{�Om IFIr Conir�c�or's L�cense ��,��p55 �•
Law! �hr, follow�nq reasan(S�ciion 7031.5, Businnss and '— � � e 1 "`),�U
Prcf s�ons Codo�: City Tr.l.No.
I,os�owr.er oF ihe properiy,w�ll do�tir.wo�k�nd!hr. �u� 7"�7
s••uc•urc is co�ini��ded or e((rr..d�nr snl?(5=c�ion ,
704a,Bus�r,�:s a^�1 Prolcs!�ons Codc).
COk5T4UCTICN IEND!�G AGENCY
I he•r.by nffrtm th�l tti�rr.is a cons�rut�ion lend�nq o�ency for
'h^oe��c�mc�ce ef ih�wc�k fo�wh��h�h�s pr�m+r�s�ssued
(S�c.9p97,Civ.C.).
Lcn�{er's Nom�
L�nder's Add�ess .
I ccrt�{y!hot 1 hme recd Ihis a,^.plicntion�nd Y�ie!!�nt!Fc ►
ahov�In!crr�oiir,n is m�mcr,I�mrtr.�o wr+ply wiih oll Covnly
e•dlno�c�s nnd Stcte laws rng�!a!m�Plunh��g,ond Fe.e6y
au�hM�zc renresentnlives o� ihis Coonty�o enler upon Ih�
cbove-m�nhored property(or inspcc•ian purn=ses. f
��� � , � _ � SEE REVERSE FOR EI(PlANA70RY IANGUAGE
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