HomeMy WebLinkAbout0786A WOR%ERS'COM9ENSAiION DECIARAiION APPLICATION FOR PLUMBING PERMIT �� �
I hereby offi.m Ihat I Fqre o carfiAco�e af consen�io�eff 7yyp7q
insure,or o cerNfiw+e oS Worken'Cpmpeinafion lmuronca, CE a�7(REv.�oiBi)
ar o !� copy rhereot(Sec.3800,4rb.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
W� ir...,arr' rNA�w►.
Volicy Nb. � `� Compom . .
f� Ce�iHed oopy�s Mrobr Ar.•�shed.
� Ctinif�ed eoDr�a fiied wirh rhe oun�y 6uilding�roPac• roa nawz�iwr ro wi na�vanaT on rrvF� e,�p� �3� �l�u
�
fiP� e l�1. NUMBEP fIMURE OR ITfM � � LOCALII\'
WATER ClQSEi �t
Dnta� Apping�n. r ��. ..
tiERflFNCAiE OF OIEMPf10KF FROM YVCfRKERS' 6n7N Tue .
�DMPFNSArOt'1 tt�1StfRAtVCE �R • pwr�R .�,v
(Thlr.netlon nNd�r b.wmprst�d(Rth�werk imdlwd Iry
Arat
Ms p�r�ntt is ke wrt h�mdnd=dopan(t100)er Im.l uvnTortv' ,�DORE55 S
I cep�y thc�in fhe pe�fo�mqnce a9 thp wvvk far wfiich this .
parrtli/iy ipueA,I atwll rro�emP�OY a^Y P�on in arry ma�ner �NK f.m' IfL. —7
w aa rp become w6jed ro+he Workms'Compenso�ion Laws. p���Q
GQNiRACTOR SO�.LLZ 1 l T'�.
pulp e'pplicanf GAtHF$WASFIER ��� � E. 'A w_ S� L �
N�TI(E TO APR�CANT: if, aNer e.wking thn CehiNcaro of SNnMM�MGFootRE(�Proc •~W'b
Exemptlor�, yov ehpuld beeome wtrjeer ro �hs Waken' �y �
Compp�at�on provisivm af�hs ta6ov Gode,you mnst fonh- IAWN SPRtNKrER SYSiFN. � $ ' �
M.ith q�IDAiy with #vcb F+7v�7lans a this pprmil sholl be
a�,���9�QkBYI WAikY1NFA1Ei! �� 3q3�6� � c�rs3
t�p colvTRacroas c�RnT,aN oa,mc.No. �
i�n?q����a�i aau Lwnfad w�da.Aaav�aons a6�havro�9 cAs srs�+ our�ers �J �/•S'. 0�+� �
tcom�h{;ncing rr�th$Qcti2��fQa of P��o�9 of U+e fi�inass IX1nEr5OVEQ .
and RoYess�om GpdO,aAd rtly licet�e ie cn(ull fiprce or�affect. S.PER SVSifM .qNAL 4
/r� �,y�Jjj QATE ,•-_....; ' VALlDA71�N � I
LicenseN �� �c.Class3�.�.� � � OC �
O DD- iWAI:��� O '
ConhoctW W�d2'�a�e�_�� � `.�z�:�.rf V l
❑ I nm eaempr under Sec. yy ,
a �
B.6P.C.for this rpotqn � z 1
Pion check fee
ooro� a�unnsn�vfleMir issun�c�s D ,� '
�
Sro���^' � TOTAL FEE 3 �tJ �
Pfon Gheck appUfaM . '
$ItdG{,f fqMILY
HOMF OWNER$U�IOFR OECIARATION Name
I hereby cfirtm�fiar 1 vm eRempt ham�he Conhaior's lics�se ;''�7 E�6 A '
Low for�he iollew�ing remon(Sectron 7Q71.9,Business and �r"s +
Rofeaions Codel� Ci�y Tsl.No. «• • • • �5 I
❑ I,m ownx oi the propenY,wi{I do the wa*ond the � • •,�,(1 rj� j
shuchne is not intended a offered f«sole(Sec�ton
�
70NI,Business ond Professions Code). • • ���.J�u ,
i
CONSTRUCTIQN IEN�ING AGENCY
I hereby affi�m ihm rhere is o comtruc�ton lendcrp age�cy ior � z 2 9�8 3 �
the perfom�o�ro of ihs work frn which this permi�is issued '
�Sec.3dfT,Crv.C.). j
�
tender'�Name � �
�
lender'�Addreu i
I cer�ify tlq�I ha�e read thlz opplicm�on and sto�a�ha��he � �
abore infprmption is carett.I ogroe b comply wirh oll County . �
ordinunces and Slr'h lows regulafing Plumbing,ond hareby
auThorize represlntpfives of tbis Counly to en�er upon ihe � �
a6o menhoned properly ior inspeclion purpoa ,
_,�yn,�,lii�C_]d.�..�_ 1 Z��I/b�, SEE REVERS£FOR EXPIANATORY LANGUAt3E a
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