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HomeMy WebLinkAbout0976A r---,-_. .._.,__._ ..__.__.____ __..__.,___.__.�.____._..._._.___,._.__._____—___..�.._.�.:�._.._ t WORKERS'�OMPENSATIpt�1�DECVARAT10N APPLICATIQ.11�:�CD�'P�LU�MB�11�1G��P��,'N11T � . `7 I heroby aHlrm iher I hove o caN�flm70�of�9�,Sero�ro ielf �yq�pp�A . �nauro,a o Mnlfieqte of 1Npfkert'(�0�11 pfCiIQIT YneY1p11[a. CE 81?�(Rfll.to�6t) °'°�"°'°d°°v�+h°`°°f�°`.aep���c.) COUNTY OE C05 ANGEL�S BUILbING 11NC 5AE�TX �Tb�32138�:�c�m Fre�ioh�C Indemn;i�y `7�.,- C�ri�iad'mpy+i FeraNv fumsahed: - rq aeaiuwT ro nu w�vaiNr de TvvF� buuA � CartifYad mpg l3 ftkd wi+h rhe co�nhr g•�nfA��- �� _ - - _i nnndeP�lnment. Fl�c7tA2�oRqEn� � � lCr.�WTr ' oare.�0'l7�8"�['i ��� p ..` ! ,w��t�tT .... a ; -.�.o-� ��AAB�RF---... -_ -_�_ _.� - ._ . . i �RT1EIChZE OF Oif�MP71QN ERQ7Vl'NVQRK��S' a�. �m� -' � ��. . • - - `,�_ CQIVIp�NS![?IONiASUR'AT�(F.� 6f1�R � _ ��R ��e. �;r� µy. �Q�. ��i$. (�1�b siutie�r�+rad ho3�b�.c9�+pI�Fid�tF.'�frw�rkinrolr�d by ih►p�rm1Y ir�[oren�•6un�Tr�d dallqyT(3.L�0)orTi.�.► ,�' wvnmRy �qpp��y I certYfy fh¢t ie iha=ppttarmqru�0�Iha�.+kork fpt wNich thia / . '� permit is issu0�,b�li7,51Y�ID?Omptay Cnx{1p�ion ie�p mGnner `''��` 4e .— CITY � m'.. � � w w ro 6ecane aubiea ra nre Warkers'et�mRematioa law�s. � ���� � _ crnvtlucroe 1 � ome a�atia,�r / aorr�rswavaR .— nooa�ss I2Z85 Ma olia Ave. ' NOTiCE�O AVP[K.'ANT: EF, afron rt1eRSnQ ihis CdnlNsute of Sw�MM�IVG ac�ot RE€..fDfrort � . � . .. - [ �r '�?pt�n yne. sj5pyict hecome aub' c��io +he�fNaken' € ��aa h � iye�tdtian Areviffons of the LOLtor�,acoiu mw�for»,- i,�,����sr,�M ��1'�.vers�id�e 925 D3 �"N 1- wro� compl� witY� �h prwisiuns ar !pOrmA tkrOfl be STA1E - � tlnemad revp�, � WAhFi�A7FR . ���. 41C�AISEG Q3NTRqCTqR$OERABAtt(k7. D�STRI[f �.BY I heroyy offkm�hp�1om Ifce�!undqr pro�diiaas of Chopler 9 l '��"" ouufss r (commenci�q.�irh Sevion 74p01 ai p�r�aipn 3 ef OieQua�neu outterSov�+ . � a�d vrofesr+nrocade,ond my license is�+fp0 f�and OPect. s�� FINA1 VALIDATION � Licerrse Numaer ��c�:.,,�lic.Glau„�._ _ _ trA����� . . V � I c4�r�o«aR.,G.K. ��:umTyi�, 3:0���85 � e� o 4 � i ❑ I mn exempf�nder�Sec. . y�n B.6P.C.frn ihin�eason 2 � Plpn chack fee , :.:(i i i.b A �� Oate:�,.,,�.d— p�UMBWG GERMIilSSUtNG FEE f ' � n.e; �:c n 5ignanne I� TOTA4 FEE ^��n X � I �.. k NIM check apP)IMn1. p� SINGLE iAMIIV � u ., � ?�.,,.._ � HOME OYVNER-8F1tLDER�dECtARATION Nome _-- . . , � , 1'�ceby aff�rm ihof I om exemp�from�ha(onttqdtor'�licerne - � n�;;-s%� � �or the folloxring reosan(Setflon Tl,Pi1.5,BlHine73 Cnd� '��°� . . csioru Code): City - - e.N -- �i� ❑ I,as owner ot�he properry,w;ll do thn wvrk and rhe - ". . . -. � � .Vuc�ws ia not imenQed or offpred-fw sS7ie(Seaion �944,9usinea and VrofeuiGAs(;qity}. coNSTeucno�v�t�G aGE�cv I, I here6y affl�m rhor r�ere is m con3lrpetfan#err�n�aMy for �. rf�e perirnmance ad rt+e v�o�k tw wnirh�b pe�thir is baued �� (Sec.3W7.Eir_C.). . Lerder's Name � lender's AQd�e,a� � . � I, F mmfy�har�hava�eod�his appliomine cnd'rip�e 6�pr+ks 1 ; atxsve i�anepnon b carr�.1 ayred ro c,qMph�ilh atuQn+�Y , I ord�wncea o�d Srate lows regukNng P1um$IeC:qrni hSlTeW , ou�hovim represenmUvss o#iRfs G`a�mtY la e�i6e u�n ihe pbo. en ed peAparqr f. �pp�en�gurpq�s� SEE RF�RSE FC1R EXPLAN7470RY'LAM�UAGE �tcR"°�'��A�,.4.� i�r7��5 Signa�Perminee Daro � � � � � ' _--- _ _ __-- _ _ - _.__ _- _. . _ __.__ _ .__ _ - - - - ______ _� �_ _ ___ . , ,' I' � AFFROVALS DATE � INSVECLOR'SSN3NA4URE INSPECTOR'S NOTE$ OVJ\cR-6UILD=P,DECLARATION IUNDER SIAB WORK ,a. �'. I here6y af{irm th��I o empr f.om the Conhac�o%s - QOUGH PLUMBING � � License Law for �hF following reason (Sect�on 7031.5. GAS PMING � Business and P�ofessiom Codc):Any cify or counly whlch '�� GAS VENT , roqukc s a permlf fo cons�rucf,nller,improve,demollsb. � ' �or repoir any slrucfure, prior fo Its�issuonce, a�so re� �� HO7 WATER HEATER . . � � quires fhe applicanl for such permil fo file a slgned slpte- ' CLUM'11NG FlXTURES � � � menf fhat he 7s ficensad p�rtucnt!o fhe provisions ot ihe � GASTEST .�}— Controc7cri Licen;e Low(Chepler 9(commencrng with � UTIIITYCO.NOTIFIED � � - Socfion 7000)of Division 3 of fhe G�zlnesz cnd Proles� . - tfons CodeJ or Ihaf he Is exempt fherelrom and the basis � c7 ' � � lo� Ih� a�leged ezr.mp�fon. Any vfofalion of Secfon , FINAL � f K(�r n�e _}rnnf � , �� . . , 703L5 by ony opplic�nl lor a permif subjects�he apph� . cant lo a elvif penalty of nof morc than Ovc hundred k � _ dolfars(5500).: INDUSTRIAL � - � . ' - � ' - - ❑I,os owner of fhc preperty wili do the work,and NIASTE APPBOVAt � - ' the srrucWre is nol iNended or offered for sale. � (Sec.704f,Bvalnoss andPro(essions Code: 7ho( �po- � � .� , - . lor's Lfcensc Law dans not apply�o an owncr of p ';Ky ' who bullds or lmproves fhrrcon, ond who does-such _ _ ..... . . ' work himseN provfded}ryaf such Improvemenfs are no�. �� � '� � � Infendedorofferodlorsalal/,however,Ihebuildingor � � . . � improvemenl Is sofd wlfhin one yecr o1 comp(efian,1he i � ' � . ' owner-builder wdl have tho burdcn af proving Ihaf he did . , � . nol 6uild or Improve fo�ihe purpose ol safe.) , I.am exempt under Sec. . '� � B&P.C.for this reason Date Owner � INSPECTOR'S NOTES I I,