HomeMy WebLinkAbout1412A (223) i� WORKERS'C'OMVENSATION DECLARATION ApPLICATION FOR PLUMBING PERMIT �
I hareby afhrm rhat I have a cenificaie of conaen��o self 7pAm�A
iiniWa,a C cerliftcote of Wwken'Compensolfon Insuronce, cR en(rt�v.toia�)
. or a cenifWd eopy�her�of(Sx.3800,iab.C.) COUNTY OF LOS ANGELES BUILDINl3 AND SAFETY
; voir�d!17 1D47 �om�„�Fireman's Fund 296/41C/Lot i2
� Grtlfisd copy ia bereby furnished. "� .
� � ��{�� FOR APpLKANf TO flll IN(PRIM OR TYPE) �"" y0665.E. Truss Court
� py ia fTbd wlih the cewy bNldlt�inspec- .
Hon dBpOrlmDm. , 'L w.1MBFR flXNQE OR IIEM Q fEE
oc�a $ItEI$� a�kan�OR ' :z7il.t?:� : 3 wA►�xnoa�* � ���wland Hei hta
' GERttFICAtE QF EXFMPIION F4QM WORICERS' 6ATH Tue � a�ss si'�olima & Ra idView Dr.
�n�5atro►r iWURn�,t� y s�wweR y� �'�''�R
(r6T:.«itom�.-.��or b:uropii+" K��,rwark Inyoirod by
. +6r�p:.mle4•�a.an,lwndr.ddo�rr�(stuo}o:�....) u,vA.an � p�ppnp�460U C8m ua Drive
� I ce'rtify fF�pf�n�h'e periormonz�0 01 fFie wd�k frx wNkh�hia . .
pstrmU ia isw8d,tihdll not empioy bny perwo in ony mannsr �"K c'Tv Ne ort Beach '�•"�� 540-0500
, w as ro 6amome W6jec+ro rhe Wakeri Compe�wtion Lawa.
� o�"�"''�"E¢ '� �TM�OR H.C.R. PLUl�1HG INC.
DCiO-' �_ ,-. �n�'4kaSN! _. . ClOTHFSWASNER
votu�To n�a�t: it, o�re. �;,w�ms c�nukor.of Sw�nnM�n�roa Re�roa � AD°�12785.Ma alia A e
- erty�tlm, you �hooW become wbjoe� w rds Worksrs'
� _ompenaawnQ.ovu�an,of itie 6a6o.c.ode,�ou m�w+onh- wwwscm�wms.s+EM crrv g;ive;eide �."p371-50A0
� wi�h complq wi�h wch provrswas er �hb psrinix tholl be
d.eR,.a,avotsd. � ,�,,,,�,4A,� � eri"c�ao. 336428 -36
+u�EN3ID�1rYn�t�s oEC,taRAi�N as�R�rio. sseo er
I heteby aH.�m uavtl an Gamed wder prov�aims d Chapror C c.4s srslE�n alnErs
j (commendnp wilh Sa[On�7000)u1 Oritslon 3 ot iho Bwlna�a p�pyEq Y
� ond Orofenio/u Cods,ard my Ikeme is in full fute ond effect. S PFR Svs►en+ F�a� �/ VpLIDATION O
� i;�a�.e N�,�,� 336428 u� c�m C-36 DATE - - 7 �
�c �
ca��,o,RCR Piiim�ing oer, Sl�+/�3 BY A` W
� ❑ I om eaempl undsr Sec. 0.
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, B.6P.C.fm�hie reoson ,plcn check fee �
oma:
, PLUMBlNG PERMIT ISSU7NG FFE S Q
S�pnaure.._.�__.._
' �OTAI fff � .� :. 1 c; i.�ii
` �lon chxk applimnt � �' . . . .
. S�NGtE fAMILY "
; HOFdFOWNER$VILOERDECIARATION A7ome g.C.�B. PLUi�TNG TNC. � � j �, _
! CF�arabr oiivaa 4w1 I oM exemprfrom�M Conwoct«'s Licenae ��ev 12785 �gIIa'1 i8 Ave.
�w fa�Iw followinp rwwn fSaction�031.5.9usineu and , _ � ,� . . .. _-
' Rofessions tader � �N Tel.No. • `,v.
' ❑ 1.at 6w+wr of tfw propwry,will do�hs wwk and�Fe �� �_ -..
� sm,.crwe ia nm interded or offered for wls(Sacnon �
; 7044�usinesa and Prahssiom Code). - - -
� CrON$TRUCTiON LENDING AGENCY
� I berehry offirm 1hW�hera ia o construciion bndieg agency for
1he psriOrriq�ce o!iha work fw whith Ihia permit ie iasued
(Sst•3ADT.Civ.C.).
�
Lende.'�Name
i
� lendei"s A1Jdrasf •
� I csrlify thbt 1 lxWe reod Ibia application and eMte�Fal Ihe ►
` abewe mformulian ie correc�.I ayee ro comply wi�h oll Co�nty
ordinonus ond Stote laws regulainp Pl�mbinp,ond herab,y
f ou�horiza rep,esen�a�ive�o(this County to 9n�er upon the
Oboua-men�bhed prOpWly for i�5pe[tion prnpOSee.
f � ' - I SEE REYEBSE FOR EXPUINATORY LANGUAGE
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