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HomeMy WebLinkAbout0969A (5) WORKERS'COMVENSATIONDECLARATION APPLICATION FOR pIUMBING PERMIT �j I h�.e6Y alfi.m rtwt I Iwre cer�ifirote of conav���o aelf �yeyq ���� re.a a mn�f� �e of Waken'Campenmuan Imo.oMe. �F ev�rtEv.�oiep . F.:d f Sx.3BOD,bb.C) COUNTYOPtOSANGELES BUI7.DINGANDSAFE7Y ���Y ran ,'� 1r�8. � � Ceniffed copy ia hereby fumi�hed. �Gehrfrod caP1 n liled with�he . 6uw1 i rox nrniur+r ro rnt w IvmHr a rvr[) lu�WCK; �+► . . rq im �� £'���i� RF33 no�Aepommep. ����..5�( �wwhrra�r �owm Wle.l�}yt�i7_Appli�ant NFAq[3i . . CEflfIF�fATE OF p.QMp��pN fItOM wD 5 enrH iue - caox Sr. � fDM14PflV$A'110�dIN5URAN� ( S1qNFR OWIgR � (ThtafieHen n•.d nar h•mmpl�t.d ff 7h•we�k volr.dbr nwn M.��1.rAur.heen•tnmanaaetie..(3YOo)n.t....) �uv.rorn qpp�ys I M�Ik���Me perfwmmrte oi rhe waA fw wh�ch flds permftahwed,lYiall.ro�empt%anrPe'son�na�rma�na. smK an Ty. .o� . so M 1012ecVme wbl�lO lholYmkeri�lfon 4mt�. ��p . "- 1 Ca+IRAROR . �. . / DotO�.�/pp�KOnl �1piHE5 WASHK �� �Iff r0 APPIKAM�If.ahx maki�g�his C.e�Nficpte M �� i Appl�qa, �w ahvold hecvma sub�ac�ro�hs vQorkers S"�OAN1'�PO°�� w �CmMs�w��wo•+•�o�n ef ine Wbv Eo9e,wu�raR�- aTr R+,�(� I wwn sren�x svs�[m a+M t9mdY�+wch e��aom w�d'u w�n enau bc srai[ S � oemad.omte4 w.�x�w�a utuu[no. uCE�D GONtqniRQR,s perlaRAr1$+ ou.a�n w. nr ' �h.e�eblPN�m.iho�Mm+iRmadonde'aw�iciommC/�nma vsrvn r'j�'ou�urs � (n no*+�d xal�n�Laol w a�+>+a�3 of ms euainm. o�mns avm l� � Yq. ' md.�_ep�..�Cak,md+hr�¢ama b��fuu hrce oad eiku. s cro smux FlNu VAUbATIOR D � . ucen»Num c.auss� ow7E gy � i ��I BY� � Conlmpp � . . e � : ❑ �OA+e.remC�uode� 6 � � i 8.6P.E.h.�1aa.eman 2 Plo�check fee , ! ��� RUMpI1JG P[RMIT I�UMG FEE S ! 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