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HomeMy WebLinkAbout0970A (5) 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 � �d0� a01�3dSNl ' ["�1 HJ 1f� � �7 ¢ [O O O � IN It� lf) W C .�y • l ri N �Y. � • • O � ^ • n'S ty- �J' � C� � �r� �s - S o � � � �^ � CI �� (� � � �l r. r ! �,�<I c- L � �1 �Q ;�,��'. < < r� � ���;'� � ° o � � � � � � 1- a�. Z � N � `� ` �: ° c�' �� O ` ' � O `� � �~ ` � . � . W� ~ `u N � L ` �r! < I��? _ ; < -�C U C O ' C .P.r.+�+ � p W C � e Z r<I � �z� � — .._, j� � I O E p LLI_ �� - ° -- --�^-�'�� �' °� - � L _ _� — - � �.�. �, �i �= ►- w I O `� N =��" z, u v ; � —' i _'I�--- ---.-1— -�I— --_._.�� 1—: U � � � F I-__.�I_— . 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