HomeMy WebLinkAbout1411A WORKERS'COMPENSATION DECIARATION APPLICATION FOR PI.UMBING PERMIT � �,
I heroby affirm �hat I fiore a cenificate of comeN lo sei( �a,q�y�q
irnure,a o certificate af Worfcen'Compe�a�ron Insurance, CE B17�REV.10/el)
m a cenif�ed copY themoi(Sx.3bq0,tpb.c.) COUNTY OF LOS ANGELES BUILbING AND SAFETY Lot 10
PoI�LCompony P'i taman�s� R..nri ,
296(33a, 2 qar �
Q (:brtified topy ia hsroh�r lvrnished. ,--' ... .,
� FOR nvw�Ca�r ro HLL�N�vR�NF ox 1rvE) �WI�� � ;
�r�r��or�r is Hled w+�h the coumy buildi��,n�- ss 0670 8. Trvas Conrt �
ii dCJ��3m prr3. . NUMBEP F�MURE OR IiEM � � .
uare ���^ApplKam RCR �y:�Q _ y w^T�'��T � 1Q�"`�TM��TZand Hei h a �
r
C�rc�s�pF�xEnlrnpKfRpnnwOR�ts' y BATHTUB � ST.COIIIDH & Ra idview Dr. �
�QMPEHSanoN n�SURANc� sHowea °NfNER P o S I
(1'hl�s�eflon rtsed rrot b•mrophf�d t/tho work linelvad 6y
fhwpiPl»iti�foront�hu�r�ddollerf(Sf00)orlsy.y � �,e,yqT�� g ����u4600 C us Drive ;
I n9rtlfy M1k»in the perfom�pnce Cf�he work fo�which�his
penhit q uwed,I ahotl no1 emptay any person in cny manrrer � � CITY � B 1F1.Np. :
ro m rob«cme wb�«r ro nee ww4en'camae^saron tow�s. � - _ - — i
o�wns�u o-a ccx4Tw�croe R.C.R. PLOMflING INC. �
Daro 'r u�r norr�s wns�+
NOriCE�o M�+Nr: �r,or,e,mok���n�.ce.ntica�e o� � ADQ1��`12785 Ma nolis Ave. j
, yw shauld betome wbjeet �o the Wmken' &����������
-�wTion�prisipin of Ihe lphor Code,yvu mvsi fvhh• i,qy�rH���R SVSTEM °"� Riverside T��1°D�371-5000 j
' �witA�ampfy wHh suich prorisio�ar Ihi��xnit dmll 6s �
demead romqke!!. � wa�a�n+�e � t�rao. 336428 ' C�36 �
1MAVSFp 6flMtRACrQRS oEeIARAx�I a wo. �er �
Ihe�el�qfftrmMrnlamU�eiped�unde�provui,waro�GhoP�a9 GA56vSiEM OUi1Eig � .
(s�g�GnunQ w�U�Seaian 70D01 oi Diri;ion 3 of dro��� 417REr5�p � �
an�TPrvfSssivm C�rd_e.qnd mr�k�se���F+U forcognd etfect. e PD+srSTFlw 3� p�NA� VALIDATION O �
licarRqNVmber 336428 iic Class C�36 DAYE 2—��.�.g/ �
�i �
co�moc+w�:C.R. Plambin¢ �e 81�i/83 sr
� "" .. . . . � W
I om exempi under 6ec. . d .
� 8.3P.C.fa this revson :-I �- I.i ; z �
Plqn ch��k fee
�re: PLUMBITIG PERMIT ISSUiNG MEE E • • • �,
�1 5�� T � 10TAL FEf g D I Y ., .,�;.� .
! Flon c�+eek applican� ° ° . .,..
� 61NGL!fAMRV
HOME 04VNER�BUILpER pECLARATION �o� R.C.R. PLDMSING INC. - �
��help¢y pffirm 1lpt I om exempt hom iha COnhaclo�i license q�rns 12785 Ma 118 Ave.
w lpr 1he f411pwing reutoo(Section 70.31.3,BuR�neu and ��
afesfiom Codel: Cily gi,verside ra+.N�.371-500Q
❑ I,ns ow�ror of rhe p.oper�y,wHl do rhe wak and ths � �
snuc�uro is no��mended a oHered For sale�Sedion � .
7Wa,Business and Rofea�io�Code�.
C�NSTRUCTION IENDING AGENCV
I hereby nff�i.m that there is a cwnfruction fending ogency fw
the performa�ce ai the work foI which this permi�is iawed
lSec.3097.Civ.C.).
Lender's Nome � •
lerder's A�dreu
I eertify that I hova reod thic appl�cm�on and sM�e�haf the � '
abpve inforrrb�ion is corroc�.I agroe to compiy with all County .
ordirances and Slaro lows regulaiing Plumbing,ard hereby �
aulhorize reprosenta�ivas oi this CouMy lo enfer upon Ihe
above-menfioned properly fw inspaclion purpoaes. ;
SEE REVERSE FOR EXPLANATORY LANCiUAGE
RCR by:`�r,ec_��,c✓J�..�.+C 8/4/83 ;
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