HomeMy WebLinkAbout1413A � WORKERS'COMPENSATION DECLARATION APPLICATION FQR PLUMBING PERMIT �
I Aereby affirm�hat I hare a cert�Hcare of conseet ro celf �aqby�q
� inavre,a o cerflifmro of Worken'Compensatioo Insurance, C4 Bn(REV.IOi9�� �
� a o canHiad copy�herwf(S�c.3800�lab.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY g1Ipt lCi
; o,i��,711047 �,,,p,,,y Fireman'a Fund , 296/41DR 2—car
� � CsAified cqpy i�here6y fomished.
� FORAPV[RAMTOFRtIN(PRINTORTYDE� �RE�.ss 20601 E. Trues Qourt
flo^lidled���fited wi�h Ih�coonry MriWMq��sPec- Nume�a Fixrurs�ou i�n @ � �m
. p;�, �'/�r/83 npo�iSa.,8CR bv:7jJ.Q.� WA1ERClOSEi � .
� C�RTIFI�ATEQFF,XEFM�IONFRWNWORKERS' 'y �TMnB sr.colima 6 Ra idview Dr.
(x6ts s�1oa peril n�o1�b wTmlo�UUR+�ht ork Inxolvad 6r �Y sHow[R ��p P. s S Ca '
� �hr P.r�ou i:fneon�'i�undr�d doUars tSt00)or lan.) UVATORY �p�g�G�O CBiRpi18 Drive
I eeniiy�fw�ie fNe perfamance of rhe wwk ta whrch ihis �
� petlrYif is issoed i tlwll noe amploy a�y perso�in aM monner s+NK nTM Newport Beach m."o371-SOOU
� w as ro tiemme s�bpc+to rhe VYorie�n'Compenaa�on laws. d5�4WASNER
. � �iO� B.C.B. PLUMBING INC.
, oare �Kon� aon+Eswas� d-p
NU110E t0 AOi1KANt: H,6he'�;��n;.c«ra��.of ��i2785 Ma nolia Ave.
i •e^'p""", ve" *he�d bee°u'° wb�e' '° n" vf'°�k°� swuvwwcrvaatc�vrat crre Riveraide � 71-5000
� .onlp�nfaA10A pfAMi8i4�ii of Ih9 iAhor Ctlull,!ou must fdlh- LAWN SPRMpCLEF SY51FM
wilh ramply with uwM Qroviabns a thie pwmN shall 6e 41'nTE
dea�+sa rovdtat. / WAYFR HEATFR 8„a u�wo. 336428 -36
�r�l�iEo c+tiNtaa�trtlRs�Ee.tnY.anda omaKr►io. ssEnar
GASSYSIFM WttFfb
� �fiarepY 0�{irm�hnF?am lkeuad w+der qrorlsloro aF Choptee 9 0'O
. (cnmawnctr'p wuii SKtttln MOD)oi OiHsion 3 ot�he Bw�na» OVEa - . }
ond itroies++ont Cada,md a�y liw�se is i�fu11 farce ond effea. s� �M VALIDATION �
�r�e�.e k�mbe. 33�428 uc.ctas. C-36
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pwu O
Conavc�a�E[ 'P1thD`6in$ oo�e $/�/$3 8Y V
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. � 1 am awanlp�under SBc. .� I :; ��. . N
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8.8�.C,fo��hu reoson p(pn�heck fee '� " " ' �
, . Dote:- p��gING PERMIT ISSUING FEE S p I � 1 �„ ...-
. S�g.wrure
TOTAL FEE Q'p • . 1 : . �.. :
Plan cfieck appiimm -
� SINGtE FAMIIY ` ..`i'� —� ..
� MOMEOWNER$UIt0ER0EQARATION iJoms t'.Q.l. �Z'Umt1lII$'� lIIC.
- 'herebynifirmrhottamexemptfromr4»Cerr�rocror'eUce'ns q�d��yy 1��� �JS olia Ave.
i � ,w fa�he followte�p raason(5ee�ion 7031.5,Bwlnasa and
� r.�.w�cad.>: cy Bivereide Tai.No.371-5000
' Q I,at own�r of the pope�M,will do�he wak and tiw
j sfrvcrors is aoe imanded ar off.red fw sale(SeUio� �
7p4a,Businesc cnd Professwm Codo).
� CONSiRUC►ION LENDING AGENCY
` I I�maby oRirm tlWlthere ca o caukuction lending agency for
Ihe pstiamonce of fl�e wark for which ihia permi�it isa�ad
(Sec.307/.Civ.C.).
I Lender'c Nome
�
Lertder'�Addreu
i I cenify lhot I hove re�lhip oppticativn and sWte thot tHB �
Qyoao inEormatbn ia cwreN.I agree ro comply wirh all CouMy �
jwdinaacan and Stafe bwa regulo�ing P1�mb�nq,a+d herelsy
'I autharize rapeasnWtirm of rhia Co�nry ro en�er upon fhe
� aboramantioned proporry fw impection purposes.
p SEE REVERSE FOR EXPLANATORY IANGUAGE
' RCa bv: •...G..�../,d��f 8/�i/83
� Signowre of PermiN Dme
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