HomeMy WebLinkAbout1635A WORKER$' NOECIARATIQN APPLICATION FOR P4UMBING PERMIT ~
I hereby aHirm` _ Y r�Mimle of coQseM � f � q �
insuro,or o cOrh �� � ;.
�vmpenwlidh la qCp,�'. CE ell(REV.70/81� I
w a�eIrdJied . b.G� �'°• COUNTY OF LOS ANGELES BUIL�ING AND SAPETY ' i
PoI�N� �� v a �,.
� Certifief!cPPv' ' -- '.
� Cen�fie�f mpp is f rok�ra�uwr ro wu M�rRnvr ar Trce� Mp�53 �(i�f - G � '•,k•' : .
��D�dep611ment. � NUNIBFR FIxTURE OR IfFM O fff
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MpTIC�TO A CWtHf5wa5MER �� . r
Exelmp�fon, '�' _b� SWMMnVGPOOLRECEVIOR � <JJ
COAhP9�5ChOM1 GQEb' IAM/N$PRINKIfRSYSTEM ��!L�7�-i-�� � ��
w�m camMr �b o.+n� n sr�tE ) }/ '
40� WATEN HFAIEA !l�SE NO.b� C�X55 %(u ~ i
0� asrain no. er •;
I hR! {gR�ar prppjppipy - Gh5 SY51FM QUTIFTS
( Q��Y�3S��Of .a �
a+d dip�qsq is in f�ll force a ��� �p-v� , - d �
.ei��3
pATE '� � VAUDATION V �
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� 1ik r'j �nt , p
�e ar V1ti. G i
empt under Sec.
6v�
.C.fw�his reason i
I �i ee
Dote'�„r,
�� vwnne�Nc vEw�nir�ssvir��s /D SL1 : i 6',5 A '
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rotn�� � , . n m s .,
' Plan chaek app�'renn{ c �
SIWGI'f,FAMItV 1 ^ � 1:Q,v li I
HONIE OYVNER�SULL�ER DEfIRRATIqTI Mame � .
I hero affirm fiw�I am ex � .. ; ;: - .
bY emP�(rom Me Co��tra��tor s Licemp Addre+s .c':.�"`' .
Law for the}oflowing revspn(Sscrivn 7031.5,Bysinea vnd \� �
QiOM COE!): CJH Tel.Nu. I C.i !—�=i �
1,ps owner�ihe prqperry,wjU do�ho vYork and ihe �
anucwre b not inten�ed a ofts.ed fw sole(Senion � 3,
70C4,Busineai ord Prpfe�tiory Code}. �
Cp�iRUCrpIV lEryO�NG aGtNCr �
I hereEy aF}irm rhat thero is o conshuc�ion lending ogeMy for
�he performo�ce of the work ior which this permi�is iuued
(Sec.3007.Civ.C.�. . '
lender'c Nome �
Lender a Addreu �
I ce.tify Nw��irore reod this applka��on and smro rhoi rhe � . I
abova infamo�ipn is co�eci.I ogroe to comply with al�Counry
o�dirw s pn tote lovn r ulauog mb�nq,ond hereby
oot�pri sen �ives th�s C y�o emer upon the !
abpve en per 'rins purposes. �.
� SEE REVERSE FOR EXPLANATORY LANGUAGE i
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