HomeMy WebLinkAbout1036 S COGBURN LN (3) _ . . _ � .
... WORKERS'COMPENSATIONDECLARATION - .. ... -� APPL�ClATIV[�l �SJlS PLUelFI�I�V r��LY��T. � .. . - .
1 fieieby affirm ti5ot 7 have a'terfificale�of consent 10 self 76A567A . .... . . .
msure,or a certificafe of Workers'Compensation Insurance, CE 84(REv.10/81� -- . �.
oi`�ce���d��co�y th`reo c.3 ,tab.,C.) COUNTY Of LOS ANGfLES BUtLDING AND SAfETY
�olic'y t7o. `-l� ompany (��- I
� Certified topy.is hereby furnished. �
fORAPP�ICANTTOfILLIN(PRINTORTYPE) BUIIDING �y �
CertiPied copy is filed with the c y buildin inspao , ADDRESS �r3• C�pO
tiondepariment. NUMBER fIXTUREORITEM (@ FEE ����ry
Dolel��Applicant 1 3 WATERCLQSET NEAREST
CERTIFI[ATE Of EXEMPTI FROM WORKERS' BATM N6 /�t CROSS ST.
A
COMPENSATION�NSURANCE bWNER
(This secfiort need noe bs rnmgleted if the work imro � SHOWER
tha permh Is For oae handred do�lars(5100)or less.� IAVAT�RY ���
A➢�RFSS
I certify that in the pe�formance oi rhe work for which�his- �
pe.mit�s issued,1 sholl not employ any person in any manner SiNK ciiv iE�.
sa as to become su6ject to}he Workers'Compensation Laws. DISHWASHfR
�Q� CONTRACTOR
Da�e app�icant CLOTHES W�HER ADDRfSS
� � � ;TICE TO APAIICRNT: If,�ofter making this Certifkote of SWINJJINGPOOtRFCEF(OR
3mption, you should 6ecome su6ject to the Workers' ��ry rEL nl .
Compensotion provisians of tha Lo6or Code,you must forth- LAWNSPRINKLERSYSTEM
with comply with svch provisions or this permit shall be SiATE LIC. �
deemed revoked. . WATER HEA7f.R ���N��. � u�
LICENSED CONTRACTORS DECiARA7�ON. � DISTRICT NO. Pp�hfy�F55ED BY
1 hereby affirm ihat I am licensed under proris+orts oF Chap�er 9 r GAS SYSTEM �$UTLETS �{O �(�J� ^\\i� � -
(comme+xing wiih$edion 7000)o#Division 3 of the Business Ol1ilET50VH! �\V 1.�.5-LX��`��'L �
and Professions Code,and my license is in full force and eHec�. 5 PER SYSTEM FtNA[ � VAUDA710N �
DATE �
License Num Lk.Class.�1�.,� � :'�= �
/ I1 FINAL �
CoNroU �Da1e `4`��— BY � � _
❑ 1 am exempl und ec. . �
8.8P.C.#of ihis revson . . . �
Plan check fee
Dale: p�UM81NG PERMIi ISSUING FEE S
Sigrmture .
. TOTALfEE a
Plan chetk applicam
SINGLE FAMILY , -
HOME OWNER-BUILDER DECLARATION Name z p��g A .
��re6y affirm fhof!om ezempi from 1he Controctor's License -
__,i for the following reason(Section 7p31.5, Business and address �{��4 • ►5
Professions Code): City Tel.No.
❑ 1,os awner of the properfy,wiH do the work a�the �
structure is not�ntended or offered for wle(Section �
7044,Business and Professions Code). �
CONSTRUCTiON LENDIMG AGENCY ,
I hereby affirm that�here is a consiruction 4end+ng agenq for + • � Q L O�O .
the performance of the work for which+his permit is�ssued
(Sec.3097,Civ,C.).
� • 1G2G0�
� Lender's Nome 1�� �r$3 ^
�
� lender_'s Address
t certify tFwt t have read this applicafion and state that the �
a6ove informario�is correct I agree to comply with all Counry
ordinances and State laws regulating Plumbing,and hereby '
author' represent Gves of this Counly to enter opon fhe
iobo - nlion or inspection purposes.
^�� p� SEE REVERSE POR EXPLANATORY LANGUAGE
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