HomeMy WebLinkAbout1417A (222) WORKERS'COMPENSATIONOECLARATION APPLICATI�ON FOR pLUM81NG PERMIT
1 hereby oifirm thot I hwve o cer�ifieata of co+nent tp fptf iy�,q ' � �
i�rsure,er o certifiovle of Wohen CompenwHon I.nurryr�Cp, CF 817(REV.10�81)
o.o tenilied�opy the.voi{Sx.3e00,lnb.c.) COUNTY OF COS ANGELES BUILDING AND SAFETY �
��(ta,)1IU47 com�„yFireman's Fuad � 296/83E/Lot 8 ;
Cen"rfied capy is 6ere6y furn�hed.
� iOR APPLICANT 70 Flll IN(PRINT OR TYiE) ����� .
C,enhied copy is filed wi�h the co�My building��,«- nooaes�20640 B. Trusa Court
IiO�d,qJ7orlmenf. NUMBER FIXiURE OR I�EM @' F�F 1��1N 1
�ro g y,/83 WATER ClOSET Rowland Hai hta
�_Appl�f,ar+�RCR bv:7h.4.��" 3 �
f�AREST �
C�RTIHCA7E OF E7(EMPTION FROM NlORKERS' '�„ BATN TUB �n� � �
�°r�vsnno�u iNsuw� sFawEa Q'""�R Presie of So. Calif �
(TMs mllen ensd net b�eompl�l�d if 1h�v�ork inwlwd by � :
lhapil'nnH Is!ve om he�nd db0an�SIOtly ee In�.) LAVATORV �x j
I csni/y rho�in Ihe perfoimm¢e af the warlc fw which�his p� ,noo�ss 46Q0 Campue Dr.
psnhil ia iuved.I atqll not emPloy arty person in rnry mvnner �� c9Tv 7EL Np. �
Ne ort Beach 540-0500
n as ro becane wbjetl�o w+e Wwkxa'Campemation Luws. .. . .
DISHWASHff1 Qa �CANT
Oa� ��icanf ClOTMFS WASNEII '
N�TfCE TO APR.ICANt: i4, phpi mak�ng A�ia Eem+�i�or °� °iO°'�u 12785 Ma o ia A .
I y�t�n ►� �hou�d beeama uvbjee� fo the Wwkers' SwunMiMGCDOdRECEviOp i
�5meer�tivn Pravis�o�ot tM lnbar Code,twu��iar+h- irv i�. �
uwni svrt��c�a svsTeM �
'w��campy w��n wch povitiam a. �h�s os.mn �hotl be �^h 336G28 G 6 ,
GIe.�1�i/OXOAaO� WATER MfATFR YICENSE NO.
U�CONIRACTOBS 4ECIAQATION � DtSTR0."r . BV
I hpreby�ENirm dqt I am litemed under prar.isions VECfwPfe�9 GAS SvSiFM '� OU7AET5
(cqmil�nnang wid�Sec�irn 7fi001 oF birfsion 3 of Nro 8usi�rosa oUrtETs OVEC >. j
and�4ofetsiom Code,and my t�cmae is in full force prd effecr. /�' S PER Sv57FM � .FINqL
�� >�G_ vauonnoN o
Lkense Numba+ 336428 �;�.��� C-36 ,
� '
FINAL Q__� Q :
co�r�o�r« R.C:R. Pivmbing,,,,1e 8/#/83 er I- � :
❑ I om exemv�undn Sx. � '
� B.6P.C.for th�s reoson � I:
Plan check fee
oma:
v�unneu�v�w�niT isswwc r�e s � y
siqnaw.a
TOTAL fEE � �
Plan chec�applrca�i �
51NGtE fAN11tV . �i �= i.�' . �
1 HOME0INNER-BUfLOE(iDKLARAiION �e R.C.R. BLiR�ING INC. , R e . . ;
1 . tierOF7V pffirm thpl I pm eKdmpl hom IhB CM�hpctp'i Licd.4Se �.��2785 Magnol�a Ave. _ ` . .. . _ '
I �w fw the i'oHowing rea�on(Sptt�on 7031.5,Business aed „
�-�ofessianCods): Ci�y TeI.No. � �'� �
C� I,ps owrror arf the property,will dc tM wwk ond t�e ; �,�.. �..., i
sCudwe it not inTended or offmed fw wle(Socljpn
7pU,Bu�ineu rnd Aofessiais Cade). ! _ – _`. I
t:. .
CANSiRUCT10N IENDING AGENCV i
I heretby affirm thal thare is a cwrshuUion lending agency�or i
the perfprmance of the work 4or which this permit is iaued i
(Sec.�p47,Civ.C.).
�
lendm's Name
lendx i M�dren I
I CertiSy Iho1 I hpve�eod this Opplimfion ond s1u1e Ihpl the � i
abpvp infnmafion is correct.I ogree to cwrply wifh all Coyply "
ordinances and Stare bws reguloting P�umbirrg,and her4,by �
avfhorize raprosenlotives of thia Counfy to enter upon the �
abpvp-meMioned properly for inspec��on purposes. :
I SEE REVERSE FOR EXPLANAIORY LANGUAGE i
RCR by: lG„�,i�„t�L B/4/83 ,
signot�re af Pe.� ee a Dare — I
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