HomeMy WebLinkAbout0786A (4) WORI�ltS'COM➢ENSAiION pEClARA7iON APPLICATiON FOR PLUMBING PERMITT �� �
I hereby oHi.m �hat I Fqre o cm6Aco�e ef consen�io�e� 7p,e,yy7q
insure,or o cerrifiw+e oS Worken CompeinaFon Imuronca, CE av�kEv.�o�Bi)
�r o !� copy rhereot(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAfETY
W� ir..ru'r rNA�w►.
Volicy Nb. � i� Compony
f� Ca�if�ed oopy�s Mrobr fiunished.
� t'knif�ml eopr�a fiied wirh rhe oun�y 6uilding�ropac. f°°aov��r ro wi na pa�r�T a+rrvF� e,�p� �37 �O
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ean e em. e�w�x axnraE oa irw. � � tocw�r
WATER CJ.QSEi ��
Dats� Applt�n. r ��. ..
tiERflF�CA1E OF E7�EMPIIOKF FROM YVCIRKERS' BATM TUB .
(Thlr.»etlortY�..d�T�bw�mptit.d��rk th�dlr�d Iry �R Q►vraEa .�
Arai
Me p�rnrb is ke wrt hw+dnd�dopan(5100)er Im.l uvn�ort�,' �DORE55 S�
I cepfly that in fie pe�fo�mqnce a9 ths wvrk far wfiich this .
{�rrtli/if�nved,1 alwll npi emP�oY�Y P�on�n arry ma�r+ar �NK f.m' 1EL. —7
eo aa ro become w6jen ro+he Workms'Compenso�ion Laws. p���Q
(iQNiRACTOR SO I,.42 1 17�.
pvlp ���'pplicanf GAtHF$WASFIFR ApDREu � E. fvy�yfJ L �
NO�E TO A7RICpRIf: If, aher mo�i�g thn Cer�ilicahs of SWiMMINGt'OOtREGEPlOR ' �
Exempryon, yov ehpuld beeome wb�eee �o �hs Waken'
Gon+Pp�at:on Orovisiam af�hs ta6ov Code.Wu mnst fonh. c71'/ . g „ �
wifR q!I[IAIy With #1K�Fx0�7lans a fktis¢prmil shpll be LAWNSFRfNK1ER5`�STF1M
AeeNE'��9�QkBYI. WAiEY1NFA1Ei! ���. 3q3�6s` � c�rs3
t�P cdvTRat�oRs p�uRnuoN oara�cr No. /� �
��?4r�p��a�i aan Jiwn�ad w�da.luav�aons a6�hacb�9 cas srs�A+ our�ers Q /ij•S. !?�+� r
(commy`rtcing Yrith SA��2��0)oi Qhosio�3 ot U+e$�inass IX1nEr5OVEQ .
and RGXess�om Gpdp,m10 my licet�e ie in(ull/�pres ond affect. S.PER SVSIFM .qNAI 4
/ �,y�y$Jjj QATE ,•-_:...; ' VAUDA?InN a I
ucenseN 3� �c.clas.sa S3 � � m ;
� ' —�� D DO wvAi`�� O �
cotinonw �ob � si' ',�L'.,J v �
❑ I em eaempr under Sec. yy .
a �
Q.se.c.F°"h"`°°'°" Plan check fee � � !
ooro� r�umen�vExMir issu�Nc�s D ,� '
�
sro���^� rorai c� 3 �t1 �
Pfon Gheck appUfaM . '
$iflGt,f iqMILY
HOMF OWNER$U�40FR OECLARATION Name
I heraby alirtm�hot 1 vm exempt fiom�M Conhactor's ticense �'�7 E�6 A '
Low for�he iolle�ring remon(Sectron 7Q71.9,Business and �r°'s +
Rofeaions Cadel� Cify Tel.No. �• • • • •5 I
❑ I,m ownx oi the propeny,will do the work ord the � • •�(t rj� j
ibuciv�e is�rot intended or oHered for eole(Sec��on
�
7[MA,Business ond Pro(essions Code). • • ���.J�u �
i
CONSTRUCTIQN IEN�ING AGENCY
I hereby affirm iho�rhere is o co�struc��on lendcrp age�cy ior � z 2 9�8 3 �
the perforn�o�ro of ths work far whlch this permi�is issued '
�Sec.3dfT,Crv.C.). j
�
tender's Name � �
i
lender'�Addreu +
I cer�ify t1q�I ha�e read th�z opplicm�on vnd sto�a�ha��he � �
abore infprmption is carect.I ogroe M comply wirh oll County . �
ordirwnces ond Smh lows regulafing Plumbing,ond hareby
ouThoriie represlntptives of �bis Counly to eNer upon fhe � �
a6o men6oned qoperly ior inspeclion purpoa ,
_,��lii�C]d.�.�._ 1 L��)�, SEE REVERSE FOR EXPLANATORY LANGUAt3E a
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