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HomeMy WebLinkAbout0304 0612A WORKERS'COMPENSATION DECLARATION ppp�fCqT1dN FOR �'!lJ��ING �'ERMIT � I hereby otfirm!hot I have a certificate of consent to self �6,q6y7q insure,or o certificole of Workers'C pensa�ion Insurance, CE 817(REV.10/91) or o ce�tified copy�hereof(Sec.3B ob.C.� COUNTY OF lOS ANGELES BUILD{NG Af3D SAFETY P�o-I�icy No.���Company . Certified copy is here6y furnished. FOR APPUCANT TO FIL�IN(PRINT OR NPE) BUILDING Q ��� �V, S C rtifie mpy is filed with ihe m bu' ' speo- AWRESS �'��.Vi•' l �fi n de rimenf. NUM iiXTUREORITEM � FEE LOCAUTY � Dat AppliS t WATER CIOSET Q� �qREST / t+ ERTI CATE OF EMEMPTIQ ROM WORKERS' BAtHTUB CRO5557. �}.� f w v�,,1 COMPENSATION INSURANCE pyyryEg � ' (Ehir sxtiort n�d nof bQ eompiv►od if Ihv wosk involvad�y SriowFR tho parmle is br onr bundr�d dollars(i100)or lo�s.) tAV.4loev � MAII A�ORE55 I tertify thol in Ihe performance of the work for which this ', permi�is issued,1 shall not emp�oy any person in any manner SiNK Cltt TEL NO. so as ta become su6{ect to the Workers'Compensatian Laws. �,R '�� CONTR.4CT0 � i DPt¢ Applicpnl CIOiHES WASHER qppRE � CE TO APPLICANT; If, ofter making this Certificate of D� j �p��on, you shouid be<oma subjea to �he Workefs' 5WIMMINGP00€RECEPTOR � � �ompanaatiort proviaiorta of the lo6or Code,you mvst forih• � TEL.N0. LAWN SPRINKLER$YSTEM i with comply with soch proviaions or this permit shall ba STA / �I�, �� ? deemedrevoked. WATERHEATER ��� • �-�' + ���N� ' �P cwss j LiCENSED CONTRnCTORS DECIARATiON OISTRICT NO. PROCESSED BY � I hereby aifirm tfwt I am lica�sed under provisions of Chapter 9 GAS SYS7EM OU7LETS � � (commencing with Section 7000)of Division 3 of the Bosines OUTlET50VER � and Professians Code,and my license ie in fuH force ond effeci 5 PER SYSTEM ���� � � vauaAria+� ,:,� Llcense Nu Lic.Class � � � DATE ��-��� Q� . r+I FfNAL 0`j Q L�' V' ContraUor Date �f iQ �A�� B� „�/ � `r �.; � Q C7 � o; 1 am ezempt under Set. Q �� a. � U� 8.8P.C.fw ihis reason , y,�� Plan chec fee � f 7, 0—� p,� Dota: � fA: PLUMBMG PERMIT t55UfNG FEE$ Z: Signature �1��O��` ��� TOTAL FEE g"Q � 1 7 Plan cbeck nppiicant � SINGIE FAMIIY HOME OWNER-BUIIDER DECLARATION Nome .�by affirm that I am exempt from the Contractor's License � L w for the fottowing reason(Sec�ion 703t.5,8usiness and a�`� ' � � ' � � Professians Code): Ciry Tel.No. ❑ I,as owner of ihe property,wi41 do the work and thC strodure is nor intended or offered for wle (SeUion - � 7044,Business and Profesvons Code). z G b�,�R CONSTRUCTION LENDING AGENCY I hereby nffirm that Ihere is a construction lending agenty for �• • • • •5 � the performance of the work for which this permi��s issued � •d 7 a 5 Q � (Sec.3097,Civ.C.). Lender's Name • F�7��V W� }� Lender's Address O��, 2 r 8 7 ! I cerirfy that I have read fhis applicaiion and srafe iho�the � ' above informalinn is correct.I ree�o comply with oll Counly 1 ordinances and Sfate laws �ating Plvm6ing,and hereby i authorize repreienlohves f t is CouNy t enter upan Ihe � above-me ' ed pr ty fo mspectivn p rpose �� (�� SEE REYERSE FOR EXPIANATOitY LANGUAGE f d , Sign ure oi P rm �e Da � � r-- . �� - �. T� _ ��»-� � C , 'G "O C L Y � ._ Cj G O- n p= Q U - �'� °a� � ° �, N �a� r ._ .. : 61 N t.� �u p C J Q'� C S]S1 G��6y ' ^t,N i V � O N ? O C . . '�c,,... -�--p O `v.O +�d, a� v� L p � Q'L � O � ,L+-o�i �di+ � F� S � u O ' �'� �o� c �c'° � � >_ 'c ° �y�' > `a,o °-o ;G.�' Y 4` C � �. O C G �+� m � � � ' fv O 6 N C � O ro O� d�y D O N � c 4� G°'.o E N E" �t v ro v 6 ° � 3 '� m Q-_ . 0 o a E � o N + N � Z ,a: 6• Q � ad.n`u 'y�� Q .. m 3 �NC � p�j�.. G ? D'` , . ' . . C;` �`t'. ,. 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