HomeMy WebLinkAbout1414A WORKERS'COMPENSATION DEQARATION APPLICATION FOR PLUMBING PERMIT
I hprebY affi.m thut I hove a certifiwte of consenf!D self �yyp7p �!
insu�0.a a cerYificpte of Worken'Compemo�ion Inw�O�ce, C�817(REV.10�81)
o.o cemt�ed copy the�vof{Sx.9BOD,�ab.c.) COUNiY OF LOS ANGELES BUILDING ANDSAFETY .'
r,ilC�bd�12047 �,m�„y Fireman's F.und � 296/41AR ot 15
� Cerlilisd cppy is here6y fumished. -
� FOpAVV41CANTTOFRLIN(PMI�ITORtYPE) �Q0617 E, Trus9 Court
[e'li}ied[opy if flfpd wilh thp CouMy 6uilding iMpec- NUMBFR FIXTURE OR IIEM B FEE
. fibn deporfinerH. p IOCAIITY .
DO10 . � tF 83 naP++com RCR by:y11 G...d��` 3 WATER Cl06ET �� NEAF�ST %
CERlfFICATE OFfI(EMPfION fRQM WORKfRS' Z. s�+7H Tua c�sr.Colima 5 Ra idniew Dr. ;
connaecasnnoN m�suwwcE ��R OWNER presle af So. Calif.
(iMs s�etton nwd not bs complNad if}In work Imolr�d by Z ""^�� 4600 Ca S Di ive '
the permi►b ter on�hvndr�d dotlan(5100)or I��a.) LqVATORY ,�u � �
I M�tihr dqt tn ihe perfarmpnce o4 the work for whiCh this
ppnlNl if isfyed,I ahCll no�emp�oy any penan��v�y A1G�ner � � ��TY Ne ort Beach t�•''p540-0500
to oafo beeame wbject to�he Worken'CompemO���ws. p�yyq�ER �
� COh1�� R.C.R. F I 4 INC. {
p� a�;�a„r cwrHEswns�a cn ,ec�ss 12785 Magnolia Ave. �
NQTI�E 1b APPCIG/SNT:14, tlftCr mvking lhis Certificqte af SW��P����
�empYior+, you shrnAd bekome �nbl� � Me 1"�fqtkers' �
ompen�a�non Prov�tions ol the�pbor Code,you musl forth- UWN SPRiNKIER Sv37FM arv g�vera ide T� � 371-5000
' w+th camAiy wuh sud+p�w�siona a� �h�s permi�slsqtl be S1AiE �
deamad+�o.kod. wn�a�aha ' ��++sEwo. 336428 C-36
e+c�rtsE1�e�rq,A�rotts�claannoa�+ � n�o. B`'
i he.eby o[ti.m dw�t m�.lke�rsed u�der r��s ot ch�e.v Gns srsr�+ � ouT�rs �
(commertc�nG wilA SecHv��RPOI of P�+�ision 3 of the 9afneas oU1tET5OVEF . � � Y
C�Pf6f�R�DM EOdO,Cnd�Ty 1iWlliO ia in 4u�1�qRC O�Iddffecf. S V91 STSiFM � �
DIATE ,/,jo�.� VALIDATION � p
i��e�ne+v�m� 336428 i��.c� C-36 Fiwu �� �
c,,,�,�„ SCR Pltirmbing oe�a 8/#/83 Bv W .
� I am euei^P�undx Sec. y�i
z ;
B.Br.c.sn.rhi:rea�on Plan check fee ► �
���� PLUMBING PERM�T ISSUING fEE S Q �
5
s�9"an„° rorw.� /2/e �7 , }. � �`' .. '
fla,�nxw aDRr<n�� r � . �.. ...,., �
SINGt'E fAMIIY .
HON{EONVNER-0I.IttDlRDEGIARAiION +�m. R.C.R. PLiJtIBIN6 INC. . • - . - .
�herqbypffirm Ihat I am exemptfrom 1he Ca+troNor'sliqeme �d�� 1 785 M$gnolia AVQ.- '
lYw fq M1ro fullowirp remon($ecKon 7031.5,Business ond ^.�: '
"- r'rOlesaiprt Godej: Cily Tsl.No. . , _ .' �
❑ k,as o.mer of ihe propeny,w�ll do the work qnd�M �
ttruc�ure's rror intended w offered fa soie ISe�+�u^ , ,
7p11,Bysinstc ond Arpfe�aions Code). ,
CONSTi[UCTION lENDING AGENCV �
I he�ebY aff�rm�ha�dre�a ro o canstruction le���9�^4Y f� ,
the perf�rmance of�hs work for which this permit is iSsued
{Ses.3097,Civ.C.). �
Le�eriName - —
I
lander'a A�drosa
Ad
I ClrtilY(llpt I Iqre repd Ihis ppplictltion pnd s�ole t�{f Ihe ,
above informdtbn u mre�.t.I agree to comp�y w�th qlkf�punly '
Qrdirp�cas arrd$hfte laws regulalirq Plumbing,arqf I�+ebY .
a�thptize repre»nfqtivm a4 Ihis Coun�y ro enrer up[�the
ebOre�mM„D�ed P�Pn�v for��pecrion p��pwes.
SEE REVERSE FOR EXPLANAfORY LANGUAGE �
RCR bp:�e,�,¢,,�,./�..�GL' 8/4/.83 i
SignaN�e�Porrimi e Date
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