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WORKERS'COMpENSAiIONDECLARATIOM AppLICATION FOR PLUMBING PERMIT � ;
I hereby aflirm �ha�I hare a car�ificota v(coroan��o calf �aqay�q
insure.a o cernfica�e oi Wakra'Campansa�ion Inauwn[e, CE B171REY.IW91) �
w o ce�+if�ee �n f ec.3800.Wb. ) COUNTY OF LOSANGELES BUICDING AND SAFETY
Po�,�Y No.u�"�2���,�Y ��r c� ��c� �
� Cert�tied copy k herebv�vrncshed. .
❑ FpN AiRICANf TO Flll IN�VRINT OR TYPE) �' ��� ',�G '
Certified copy is flled with�ha co�my building inspec-
+lon d +ment. ♦ � NIIMBER H%TURE OR iTFM � FEF
( �a�tirv k�e,v l�
Dota �D TPP��Sonl , O�.µG� WAi�RGOSET � O� NEAREST
TiFI TE OF E%EMPTtON FROM YVORKERS' BnTH Tue n �� ��ST� .
COMPENSATION IN$URMI(,'E S�OWER O a'�'�p (�r. J� , L �
(Thla sMlon nMd noe 6�eomplN�d if th�eroik Inrolr�d bp � �R '
th�p�rmR it lor on�hvndnd d011an(SI00)or(nf.) Z uvntortr w ppp�,u .
i�ari�fy rh��n�he pe.formance o(�he wak for wh�ch rh�s
permn is issued.I sholl not empluy any pprson in any manner � C{�Y tEL NO.
ao m tv bxome wbjea ro�he Worken'Comperrsoeion Laws. p�,q� � �
�nooe ,C s Co�i 4 t l'��'t
De�e... �vp��cam uor�swawER noDl.t�55 {�� � IJ �, � �(
NOTICE TO APPIKANi: ii, ofler mvk�ng ih�a Ce��ficvro ol
Eeemprion, rox, �hould baecme .�Dien ro �he worken' g'^��^""^����P� / �? ,
Canpamation poviaians c+lhe Wbor 4ode.Y�V mw�fonh- UWNSPRmqk715r57FM � (i'1 S 1Et.N0.��- �6 4 3 �
wilh CpP1P�Y with avch prpr��iom 0r thia perm�t siqll 6e STA�1� �C
deeme6 rowked. yy�p�hp t�9E NO. Z �� �-� GA55
tl�WNTRACT�RS pECiARAfIpN dsTRKT NO.' PRO�EO er '
I helptry pHirm Ihq�I am liceresed ynder pro.ia�om af CF�opfer 9 GAS SYStEM Wi�PS �� •
(commehary xrlth Set��on 70pp1 of Diri:ivn 3 ot M�e Businesa O�ig pyEp Y .
a�dAtifesaia�a tvde,ond aw��cm�ie is m 1u�1 fac///eandeex�. e vEtt mi�n flNn� VALIDATION d
LKEIIiONVT�/ ` O �+ K.��O9i� DA� � ���J� V •
/' FWAL /' � '
canh4ao,4•3.e6 Lao�S'� par, � � Br {�+1._l-(c4%''� � '
� i Om exempl V�G�5![. W .
�.6P.C.ior�his reoson � z �
��,� � Plan check fea
-'� y
PLUMBING PER/WT ISSUING FFE S
SigrR7Me a •
fOtAk FE4 � .. I c'=- !�. .
Plon checL oppi�mm � • • • • „ •
siruGtF faunv
+rOME OWNER-BVItDEi1 DECL1RATiON Nome I • ,..,:`i.:
I herebY aff�rm�har 1 am exempr from�he Con+.acbr'�lkense Address -
law fa�he follow7�p remon(SeUion 7031.5.Business and • • , , .. .- ,
�ofp�sions Codel� Ci�y • . �
a iel.No. ;
1,m ownx of the proper�y,+�nll do rhe work and+he G 1.� i"':^
i
tnucrure�s na�intended w olfered ia m�e (Secr:on , .
704d,8usiness o�Rofesl�ons Code�.
CANSTRUCTION LENDING AGETJCY '
I herebp affirm that�he.e i�a construction lendirtg agency fw
ihe peAvrmanc0 0;the ww1 for which�hia permi�is iasued �
I�.309�.Gr.C.).
LendOr'a Name
lend6h A�dress �
I cerniy�ha�I hare read thi�ppplim�ion ard sw�e�ha��he �
abp+e infanmtlon is conecl.1 ngrpe fo comply with all Gounty �
o.dlefanees arnf S�a�e lerrs.egvicring a��mbmg,a�d hde6y
authori=a rewesentar�res af fh�s Coun�y�o enier upon ihe
a6we me�t�o�ed ropMy fa iMpaC��o�purp � SEE REVERSE FOR EXPLANATORY LANGUAGE
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