HomeMy WebLinkAbout0971A (5) WORKERS'COMVFNSATIONIX{IAlUT10N AP�LICATION FOR'.PLUMBING PERMIT ���,'
I Aereby aHirm ihal I hpve cerilicole of con�enl ro mlf ���q
o cevli/imle of Wbkeri CompeMGtion InauMMe, Q BIT(�.10/81)
���`j�`��n'1°6���� COUNTY OFLOSANGELES BUILCINGA USAFETY �
comw�vJC��.
(.erti(ied cqPY u hembY fumished. ���� 1
�MNtied wPY is Fled wHh rhe c b �M �Ort nvxifAHi io r�u w IVRMi cx tra) nnoRESt ! ',
�COP011m nl. . � NUMBEN F1%TURE OR IIEM � FEE
IOCl1NT'
oma�appu,nn� w�na cwsEr ���5r i
CEI[tfflCf�iE OF EXEMI f1ON FItQ1A ri0 enrH rue CkO�ST. .
CONW[IVS/1TION INSURAIVQ '
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+hs�p�rmBn�k.e�nhnmlrod�delinn(f'IO�e.las.) wvnroar ``�
I eqlilly thm in�he parformonee af ihe wak 4d wh��h thm � �
per11111 nipued.I Shtlll�M emP�1'a^P P��in mry�mvnner � CITY �y.
w m ro become ab�b�+ro me won�e�s compe^wno�ww,. py�,py�ER . . � .
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Ic MM 6eieon i0401 of uryw�on a af ihn euYrroa ovnn5amt >
a .qr�lb.�'�CpRe,pm1 np Ij�a u in lyll Ipcea��'�d{eBB�t. S aER 615fFM FINAI � .
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�e:-"` ftUN1BiNG VFitM1T ISSUINfi FEE S
scp��.e �0 9 7.1 A
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Non ehe�1 app�uanr .
SINGIF FAMIIY ��.�v,��O
NOME OWqER�BUNDEP OECLAFATION Noms �
�eb1`affim U1o�I om eMemW('om Mw Co��w[b�'a 4i�O��e q�.las .�C,�.�I 1'J s
.j 1p�ne b�lowing rp�fnn($pcnon 7671.3,ewineas and
Rafeoioru Code): City Tel.No. O�.� �"H�!
� i,N mmw af�hs poperh,will do�he woh e�d.ths
sRunure o rwr mlmded w affarad for nle�Se9ion .
7041,Bu�ineas ord Rofm�ions Cade�. '
_ C70NS7RUR�ON IENDING AGENCY . ,
1�`�4by plfirm Uqt lhere u o<nnnhuctiron lendi�p ogenq fw
the pe�fwmvm.a af Ihe work la which Ihu permil i�inued
(5ec.7b37.Eiv.E.). ,
laadm i Name _ _. '�
ie�der,n�d.e,s
i a+wry�n i ho.�e�ead iha.aimFcaro�o�d swro��e �
abo�e formation is corcKt.I opiee b camP�Y with all'�rynty .
ordinonces md Sla�e iaws.eg�la�ing Plumbing.and hereby
ou�hv�ae�ep�exnmri.m of�h�s Ca�nh io e��er�pon�he
obor�tiQned v J� ��on p�.pwes.
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