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HomeMy WebLinkAbout0976A WORKfRS'COMPfNSATION DKIARATION ApPLICATION FOR PLUMBING PERMIT I Mmby aHbm�Mn I have ron+M1 qte of<onsent ro oelf �yye�� �. nauro,ar a�ert'rfiema of Worken'Compe^am�o��nawance, �ei�I�v.ioiai� �°^„' ' �5"`.7Bap,�°b�.� COUNTYOfLOSANG�LES BUII I G NDSAFEiS � O�°�'° . m�m�.trr- y-� Q,gqqied wpy h here6y fum�sha n[� C enifie d<opy ie hY e d wifh the 'idin p in - �'�K�N�b FILt IN IPiMf OA TVPEI � - SF�f. ', 7" 1101� I. NUMBER i1%fUiR OR IfFA1 o f� `�Y Dai9 1w�AOP��SRrtt WYtFAf10g� � � � �IFI�ATE FJ(§MPfIQN FItOM p7- &1TH i11B . . ' noN nvsuaar�� 1 «,�cR ( _ mf(t�m�on nn,dnef6emmP1�@Mevrorklmoivadbr ��p �M - fh�pr}�nitlikrnn�hpndriddetian(fTdo)ort�ss.l uv�Toar no6�E55 , I c4r11h dn�fn Qro pertormnnGe d iM wuh far which�hls '' Pn�q asuRd��nhpll�wramplq ary pmron in q�ry manner �'M C�n �'�- ' � so m b�aeama wbfea ro Te i'torkeK Cam�xma��vn Laws. 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