HomeMy WebLinkAbout1591A (9) WORKERS'COMPENSA7�ON DKLARATION APPLICATION FOR PLUMBING PERMIT � '
1 hereby affirm�hot 1 hore a cer��Kcote af consanl to self ly4eyq
cnsure,o�a ce�hf�ca�e of Wwkera'Compenw�con Insurance, CF ev(RFv.�oiei i �
or a cen�f�ed copr�he.eof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. � Cpmpony '
� Csrt�fced copy�s hereby furnishad. .
OfOR APPLI�AM TO F�l W(iRIHT OR T'OE) B��S �3�p�0 t� Y
Ceniiied copy�s fil�wi�h�coun�y b�Hd+rg�mpec-
t�on depanmen+. NUM9Ex POIfURe oR rtEM � iEE
io�w*Y ,aN�o�rd C.�e. / 6s"
Dote�_T_AppliGont WATER LWSEF fJEARE57 '
CE1[fIFICATE OF E7(FMPTION FROM WORKERS' Bnfn iVB �ST� '�w e.�k �.� �
CAMPENSATiON INSURANCE S��p owwEp ��,p�� �'.. �' .
(Thl�sMlon navd nof 6s eemptofad if Tha nark inrotr�d by �
tha permlt Is foe on�hundrod dollan(SI00)er tass.) �yqppRy �'�� � Fi, S
ADDRE55
I cenily thai in�he performonm of�he work for which rhis �
permit ia issued.I�hall no�emplor 4^Y Pe�son in any manner SINK C�Tv � a� iE�;.Np.�I���3 .
ao m�o become sub�ac��o�he 1No�ken'Compe�natiqn lowa. -0��w�p � �
/� CONTRAROR
Oote e^�ieanl !��`�� CIATHES WASMEa �
NOTICE TO APR1GqNT: li, efter 'king�his Ge�M�mte o A�R�
Exemp�ion, yov �houtd becom a�b�en �o �he iMorkers ��������'�
(.ompenwiion prorisiorn oi�he Labor Cade.Yo�muy fonh- Giv 1F1.Np. ,
with r�mply wnh suc� po�is:pns or !his pOrmit ihpl', be ���INKIER SVSIEM STATE LK. �
deemed re�oked. yyqhR�pf¢p ��J .� ��I10Erv5E NO. CiA55
IICENSED CONTRACiORS�ECLARA�IQN rn57RKi ev0. D ev
I hpreby aHirm tFqt 1 om IitM1SBd undC�p�OviSiO�y 4f(nOP�C�9 �SVSf6M ' q,17ki$ /� -`.t/.��
ko�nmencirp w+�h Senion 70pp)of D�rision 3 0�Ihe 8us�ness OUlltTS pVER �'
o.
ard Professiom Code,ord my licer�e is in 1�11 fwce mdeffecf. 5�Ep 5+51F�N FINAI ' i VALIDATION O
DATE ��' �C V
lir.prrse Number Lic Claa c' p� '
FlNAL,.. . � � •
i
Ganfrotlor- , . Date - ' BY '....1�I..i�'-� V
� W
I pm exempt�nder Sec. N '
B.BP.C.for thiy reason Plan check fee
Dara:
PLUMBIIVG VERMIT IS$UING fEE S f, ��J : � �r.I r;
Sigrw�ure , `- .
TOTAI FEE rr.y�"� . e � s a .
•j
vi��h�a�iK�.,� I • ::C�['
�INGIE PAMILV '
MOME OWNER-BU1l,OER pECIARATIOIV Name _ '
I hernby aflirtn thol I am exempl 6am Ihe Conhacfor'a liceMe ' v •:�i�-�.';:
lpw For the fulbw�ng raason(Secfion Np1.5.Business ond �� ^ .
Aofessione Code)' C;ry TeI.Na.
G�:iL•-f:�-
� I.as ow�r oi�he p.operty,will da fhe worG and ehe ,
snucwre is no�infended a oFfered far wle(Sectivn —
7Wa.B�a�ne�s ond Profess�ons Code). .
CONS�RUCi�OM IENDING AGENCY
I AarebY offirm tlql lhna is a construction lending agancy}a
�he per(wmance of�he work fw which rhi�pe.m�t is iuued
LSec.3097,Civ.C.).
Lende�'s Nome
Lender's Address
I cen�fy tlw+I hove reod rh�s applico��on ard sraie thu��he �
above�nfama�on is conect.I ogree�o comply wiih all CouMy
mdimnces and S�a�e lows regulot�ng Pl�mb��g,o�d hareby !
ou�ho��:e repmema�ives o! �his Couny b eNer upon the .
a6ore-men�ioned properfy frn inspecnon pu.poses.
�,���,, � SEE REVERSE FOR EXPLANATORY 4qNGUAGE
���'� � r ,
IS' o+ure of Pmmnree Data
c�
C D r O r N cU.-.. Ci
't�� � '" N " � '9 �� N
i�G' i� � r�'. tL S �tl b = �n .�
7 � ? 7. " �. "v
_ - :,ic Q �'' Gl � G� C o� a;
� c'' ' " '� i U
a`' 7 K, > O y
1? -Vi C � G1 7xc �.
. - �'� u
vL�
1�
�,�
' I y
_,
��
z �
N
. � ,;'
� ^ �
N
� �
.-� tn
. N
2
� D
_�
G
�
Z
�
�
O
�
�
� 4
U -
n
N
�n n 3� ° w c �� -
Ci_� � O �' �0 O C -0 N ']
o � � EEoin� o � c�.o ; = -±� M ;� 5. � �Nn'
� o =� q V � Nn ;; �
O � � � °�v n' x,o '^ n '-"- ° v,T n� � ^;.�. `^ �
n �� 3 a-� on, a '=�cU'^ � �° o „p ° �� ' co ., c
� c � qzc � �, _ v.v-� n g . o�c �2 = ?
� �c� � „ � �
CJ � �1 % O�. A q� u4i'o y jb +C' O���c O�r _J� ; �^ �? � �
�� 3 m 2.0 =o Q� '" r 'o ci• W - o ' " r� _ �� �
"8 3t �o� F � < .' ���. = o� '� =n 'cv' � a:
� � 'n :. o � a� ': � _ „ T�:m ._ c' p '.- C
�^ i ° -r�°-u.�; $ o '' °. �� � N � niL��', r �� Noo '-
fl c� °J a o a� '^ Q�; _ � -z, o � i 1 �-, ' �" ^ r1
f ' 10 � 0.c � _ � c O =' :c
V N � n ' �n u. O 'O (p.,., O p �c u A N � � [:.= f
o c� :r?° p o c=s 3 = `0 o c" � : �,c: �%.
7 !� S tC � 6 7� n (• O C �� ^O n � n � ��
� A tf 0 _H �� N '- j:� j _ %� `'o �: r, ��
1 Rj c' � ... � � � in n �_, tg _� R _/' � �.
� TS 1D K O s � O M 1' •. C :I � R � �V :) C �
� U 7 �I i. � � C r : �E _: ` � M ;'O.V,- � ' �
1 0 O�(� �0'D � - O L. _' ^'C , 3 U T7 r� �� n :n • �J
O TI O r O �-O C�j C [t Q 4 � N y � p C O `• n � �
„o .�- � ` ^ �� ., u .. cn ii � N � � � � n i; ` n
u n '� t� - .,, . . n c � i,
n �. o z3 •�o ii �i � ' � i� � o�^ ' r-= �
R' � A r. � =o Q � . .� ¢.^ - � C �' <' y�;
u�� c,� r c,o < ; --_ -� �, 2.,_ : �. .
=a'� ' o-, n o ��� ��� �� � N � � �:c�:
� o -- �,
' : o i�n � � � ?' c ii � c o _ :i � - ; �,. "
��O C rT.� �^. .._ ��L'��_� ��._.�_�..
� ` �
.^•�� �-�