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0970A
WORKFRS'COMPENSATION DKLARATION APPLICATION FOR PLUMBING PERMIT �; 1 hxeby aff�rm thoi I hvve o canit�caro o(c em�o ae�� W a cerlificata oF Wm4me'Campemo�io�InsurqrKe, �p�Igy.�prgl) ���""m,�y p[�ry(5".�e°°,b6.e.� COUNTY OF LOS ANCELES BUIL ING RND SAfETY � p CTTWI`�t7'���� ,,IIffww.... . . 4/4fied eOPY i�herebY fu�nqha����" fOP APPLIfANI T0 Fll M�YltpYf pq Typf) IIqNC �� �'L ' CanNivd mpy h filed with�he b�ildinp m T � Ifand lnt. NUMHEP FIItNREOPiiEM O 1fE IOCAl1iY � ppte � APpliSeql WAttRCIOSEt ��5 . . ��,����4M�, a �,�r�a ��.. � COMPENSAAON WSURnNCE B��p OW I (ihls fefllw!nNAa1e!6�eempbt�d R ihs work I�neh�d bl fh•p.nnk 1a tm oM�untlr.d doilun(3180)o.l`s..� a�A�� ^N� "�^ n ' I SAniy Un�in d+e pehw�no�ee a��he work lor whkh iha , pwmit n ipyed,I�fiqll rqt emPloY any psnon in onY man�ror � � G�v � . m m ro 6xame wMx ro�he Wakan'fomPenwrion lowa. ' olSMwnwEa Cp1+iRp[T(M. ¢ . , pa�y r.�J: 1 QOIMES WA51�9 l�OORFSS Q�� ' �II;E 71D APP[1{^ANT:14,afln myki�p Ihis CerllFicule M . mplfOn, 1'W �hWM Eem�Te m1�'ed b tM Worlten, SW�MNINGPOOL4EQMOR omRsmauo�a�.�o�n a me�bo�Code.Yeu mur fMh- CnY m.np�fb�'xj Nh�pmP�r win,rw*aovnbro m�hn 1+u^��r ahoi�ba awrv 5rtnwneo svsrrn+ �h uc. deem�d�ovaked� waRa w.nn tIRNs[.q. owss . LIQT�p fW1fRAtlppS OBCGARATIQ�y pytp��. I her9Et!4��m�M�I mm ticpmed under povi�iom ok GMpte�9 GNS sVNNn WI1ET5 ��anme���..+a�s�no�mool m aro��s a m,e�mm, � !D �a,� , ., ondPrtferqomGrode.and�ryGcemee�nluliforceondeH«�. samsrsrtr� � / VACIDATION O � �v �. liepnM '.CIpK�._ � ; CantqnP .. � �e `� B� O : � : ❑ i om e.enro�niMer a B.aP.0 f«mu�eoso.� Plan check fea � �� RUMBING PERMIT ISSU�NG FEE S Q � 5 p 9 7.0 A siqnowre lOFAI FFF �.•�.•S . swc�e fa�rnv ab��n�,�,<a�r I•1 0 2 0 0 �ow�r+aw�oEr+o�cxnw.rara r�e •1 v 2 C 0� }bY affirm ihm�am easmp�hom�he 4mnocror's lkame Add.ns ' . _3 la the follawi.p�eo�on 13xrian 1037.1,eusi�en omf v.Meurom Gede)' Gh tei.No. 0 1.1 1—8 4 � ❑ I,m owner W�hp prpperlr,will do�M1e woA ard Ihe � mucnne�a 1ror imarded m aNe.ed Iw wle�Sen�o� � ', 7W�t.Buair�eu and Aofenimn Coda). WNSfRIKTqN LkNDING AGFNCY I hereby rMirm IM111rore�s a consnudion lemli�g ogency lor �� �he pe�ipmanro of�he work for wNch ihrs promn�a�suvd � (Sec.307��Ci�.C.1. . leMer'+Noma Ler�m'+ILdO�ees � . . I�rniy�hT�hove reod Min oppBwrion mid srNe ihe��he � a6orp IMnnplmn' t.I agree to<omply wi�h oll County ordinonms ond Sto�e�bws reguhtinp Vlu 6irp,and hereFry , au�Aaue repreae�uo��res ol i�s CounN ro e �po�r�e - e�r p f �mpecue�pwpe�ies. SEE REVERSE FOR EXPLANAMRY IpNGUAGE ���U'iD`! ' �. �g�anrro of Perm� Doro � hd0� a01�3dSNl � � � FI� ¢ c0 O O � I N It� lt� cD � �, ��� �d • •- •- � > � � • • • � F � � r� I � � � � - ' CI �rJ �s. - __ o I_ � � � � �� �� � � c �+. � �,�,b'�,� � � � Q v���h.-i �C: � o � � ���.r �'�I L�.1 J �' � 3 I J� e. Z � �� Q' Q: O N �I Q "I � � ' I T �F~ ` - � ._W;I F LL N L, < °� < I��? _ � < . � . � 7 C I U I�C C - � Z C< J Z U - C ��- �F� O J � u - - p — � -- O-- --�-��i �II.�...� O� - I Z w ��1 f� ��' �`I NI � W �' LL - - I--- --- N _ �,� ( ) � W .I__ _I. _'_l- �{_"--.'��.� �i v `� ! U � �' ' ; �� I = W I � z ; , . � . I i � � c � � v, Jy F- LL ' ) _t t' } Z � J> ` I ' I �F- � ;� 1 I (7 W z �� �J C LY,� UE C n F J J � i> 7 � _ � J (I I Z I Z J � � LL O'O- LL I ��i �� ,C I J J H �\ J �/. � W J:J �Q L ? �: = o1`+�W LL i ,��y � ;� � I � � � �~ ` } �; � ' � �' �: , w ' ° '- o � V� 7 O c F.I . .n J I I7 �L,' _ I d�i F- F- _ F O� ¢� u, i � c 5 �. �^I I �'� ( 4 > �`v,`�I o '`' = U p Z 1- 7 � t� O � a�J h- � ,' � ,., � 1- } �. U J F 4 Z tt'. u: V 4 v�� � W �7 r r,� C J a C i a -. II -. C � > i�� �j � L U � I�Jn�, � I 1111"� - c�.i �4 E °-° o c � � C ` C� v1.�� �i � L i ljn�/ l/� �� ��+ � L' �� J „J � �7' '� C ��' �p �n � ° p -_ � n� i- � 7e t- (�'�� � i � c � ��y � � n� v 1 > c C C O��• Z' > 7� u ��/ x i'' �% �� V N� �/ Z C n u �. F C < c V� > __I LL. S _i_' u � C � � ,/1 � C !1 I z v: _ � •v -�.:u.. � _ C � C Y ._ �O > 7 � > Cu. � I� �^I_. �I J Cr ❑ ~ GC+ ~ C � H FL r �m �_- O << U V V N-� ° � I 9^ _ _ ° - ��' E- �Gi -- - _ _' _ -_ � _ � = 1`�'� � x` - c - �.' �U`C ^j� _ Lo C .�o - � __ _V- __ ~ c � �� 1 cc ' =F` `` c_ ,�,I �� ^ " -~" _ - 9 J _ -` 1 i c "�,_ _ N� - (I G � - l.- - ' ..? I �U � -_ � =- _�� - - ` _ - ' _=- vl MI = - - _ _ - - :== F' = M � � - `-'��- -- - - - � _ _ _ J =C j f � � � � � _ I _ - � _ - - _ G C %u- _�_ _ - �`�J � C: � - __ �CT � _ E` - - � - "o I - _ - a, c ' _ - ?oE - ^ _ - ` _ - ,_.� -__�- N_ � _ F"C c.? v -_ -' -�� Z/'7 = - ,= c- - 7= -_Gy_ J .+V�c = /.'� _ _ �..,_ - I- _ ^ Vli _ _ C, _ _ _- - _ i^L�:J = - _�. F�� .- .. ^� - ! - 'v�V� � i... � __- _ ' -, �:J _ _ _ °` --. - - NJ`� - ;, _ �� �`�C�� " M `�l •" °� '- i: ' _- t "-° � �j _ ` z - � _ � _ o```- - _ _ _ V�O '� t� _ �E - _ _ - - �=�E � C _ _ _ ___ U�`. � _ C � I•= _�_ ' - � _ _ - . __ - _ ° _ = -_ ,..t[ _`-'� ' -�� C.� :`_ ' ' r1) _ _ -O rc�E" : �.� i - _= ...c _ -^ T�� _,� -=Vv - '_- � � .. �'(`Il J = _' ��r`�� ' �r- ' _ �'1- _ �n _._ , ��❑ �C _ �= _�� � ;_�=E -� - _ � � ❑ _ -=- J ❑ _�.°_ _ _-_��_ �,..