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HomeMy WebLinkAbout1789A (10) _ _ - - I.�-.�,a.a.„ - � ...- _ '' ��: : : < v � p.. � ., a� ._ ' ��` /� /��yy� /� /�n a� q : g�(+¢ � N%ORKEIFS COMFENSATION DKLARA710N � � �, �yPPLI4l1�1 IL/� ��.61C���FY1�1�� P���fYl11 �s�i:� ...^,���s"`��_' .. I he eby of�irm ihat 1 hov�o ceriif m�e of conseni io salf � 78A887A � _ _. - _ � � nsu a o a:cerf f mte of WorKeri Compensafion Insurance, CE 917(REV 8i86) -�� � � � ?�"'r C'ei �ed co� there i5e 0�0,Lab C.).. �����Y����� '� � COl7IdTY QF !OS ANG�LES . DEPT. OF PUBLIC,WOR,KS � . .P�o_Icy o .. ompany � ��`v.�`�'!•, . _ . .. .. �. . . ._: ._.._<.. Ce t fied copy s nereby furmshed � , ., ' a�w- «. � .� a-.: - . . -:_.. FORAPPUC?,MTOfI L N PRINTORTYPE).. . BUILDING. � +I"..,` . . �. �t � Cerufied copy s filed wtlh the county bu Iding inspec- _ ADDRE55, a�L� � L� („�(l..�N L�i �_.� t on departme f Nl1MBER FIXiUREdR{TEM �- � FEE . - . . . ..�"'� LOCALITY r� . C „Ks� , ._ . .,.- ::l,F. __ .:-;7„ _ ',�: . �� WATERCLOSET .__ . . _ IA�"'tE�NU . . _ ._ )Da7e s�=em#� 3 , L Appliqont .. _ � . ._. . NEAREST'� - � .. . ,; C�RYIk�I�,4TE QF EXEM'PtIO�V fROM WORk�RS �_'` - BATH-1us �- � _ CR055 S7. " , _" � :� t �- COhiP�NS`AiI�SFtiNSURQ�tCE .' ... . . . OwN€a �� �'3�— ,': . ��;� : ` . . , _,:�n ��,�x ,_n_u,�. � � . . sHo�� r� _ �:T�a ,�.�. (Th�s section naed not be aomplefed if ffie war�C_mvolped liy� _. ;�.The permif ts far one hundred dollara(Sr60)or fess) -� - tAVA70Rv - - � - �'�� / ,_y:,.. , . , ,-, .-.�, . _. .,. <e. .. , _.. ,.:. .e ADDRE55� .�J. �ii �A-S� x'�J C.JC+�.' I cerrfy lharin tke performance of;the work.fo�which this � - �- � � - -� �;"perm f s�ssued,I sholl�no+emp}oy any perwn in any manner -� - - S�NK � � - i CiTv�- � - � � � �� tE�.�NO. - � ' so ds to become sub�ect ro he Workers CompensaLon Laws. -� pi5HWA5HER�-- " � : . coNrnac7or[li�Ll.�"c � tll`�U�.i G.,t:'.�Y Date � APPlimnt � ' _ � ' --..-. ' . _ CIOTNE5WA5HER � .. .-- � - � �- -� - - - - _ AODRESS' �! .�� . . _N(3T10E TO"A'1'�PLT�ATJT�ff afte mnkmg th's Ce-tficate�oi � . � . - � ' ��2 �al+�`'�i i'_"`�aie � -- - - � Eieempton you sFSou�d�become��subject to�-rhe Workers' - SwirnM�NGa00�eECEaiOR �� ._ -_ - �. CIN rn .�'` 7E[:NO. Compensation prw�sions of ihe Labor Code,yoy musi farth- - � �- � _ rq- <,�j- �(�J�'�� - `tlifh comp(y v,�Uh such provrsioos:or fhis permit shall 6e . �AWNSPRINKLERSYSPcM . _. - .._ �' . _. _. . . . STATE ,� Gn _._. . L1C.` . .. ... . deemed reyoked - , , �� - �WniER HEn7ER- - - UCENSE NCf. -(�j[,.Z.. CtASS _ !Y<,`�ENS"ED C'dNT1FAC1`OR$6EC�A`RAT�O��"' -_ . . � pISTRIC�NO:." . �r�55EReY . - . . GASSYSTEM OUT�ETS : � I hereby affirm that I am f icensed under p ov swns of CFaptar 9 - l - � /'�� �� � � (commennng-wi�h Sedion 7000)of 6vis�on 3 of.the Busrness pUTCETSOVER �" --"' � � �, and Profess ons Code and my I cense FS irt full force oad effecL 5 PER"SYSTEM �- �- - - FINAL - - � -�-' � Y �L,. < ._ » � _,._ °- � VALIbAT10N License Number r l���� - Lic Class- � ,.- . .. .. . � � . � DATE� �� ` . �. . - - � -Nti .- g �.y::- ,,.� . . . ��'1A�.LLs%fY�lft""��t'� -..._,., ; . � . . - FINAL� � � , . - , .q,� �_;.`; _ Contrador ..'� -..:..�Da�e �}.'�7'�J j . . . . . . BY � . . rm��,- ,..._, �,._.... .._, . . _... . '' ;� I om ezempi u�der Sec. _� . . . . .. � - . . Qw. _. ,. _ . - - - - N3f B 8�P C�.,for th s reason - � �- � � - - � � Plan check fee : �Date p��/�1gING PERMIT ISSUING FEE$ ��_� " S gnature � - TOTAL�FEE ���C'„�('� . . - . ` � �� - � Blan check oppkicant - � � - � - �_ . . . . . . - .. S1NG[.E PATA�G � ' . -. - . - - - �- HOME ISIANER BURDER DECLARATION �.. , Name � - � - �� � . -- � � . � . . . - I hereby offilm vhat I am_exemgt irom ihe Zoniiacioi s Cicers'se�� pddresa ��- - � - � - - - - � ' ip *or the-following reason_($ec�ion 7D31.5,Susiness aqd . � - Profess�ons Gode): . . . . � � - City - � Tel.No. � � � .� 1-7-�:��/A ,. ❑ .,� . _ . . �. ' - .. .. .. . .. � _. . . . - . ... _ , -: __ ' I as cwner of ihe property,will do the work ond Ihe � � . - ' � -� --. ?n�a � o-�-a� .' shocitir`e s not mtended or offered for§ale($ection � �� " �. -�� � �-. � �-.. . �-� �� �- � � .� - 7b44,"'�us ness and�Profeisions Code). -..'� . .. . .... . . . � . j. �.:,1�u-�.ri. -: `"CONST�CtCTCONIE(�CSING"11'GENCY:. ` � , . _ -. , - . ., , - . . .<_o� -e .c,-J,���: .... _ . . , , _ ,. _ _. .., - � ,_ �.. _ _. . _. � _ , � . : , -. . ,. ._ .,. . .,w, . ,.� ,:,. , , - �- , I he eby af4irm i}ipt tHere�s a tonsiroction�ending age6cy for . , � :lhe performdnce of the�work for which rhis permit is issJed � �- � � - - � � .�� ; �..._q��� � � . .,'�$ea 9097,Civ.C..)� . -- . . ��- . .-_.. _ ._ . .,. __ .::.;. . . . . - h .,_ :.: . , - -. � - . , '- :a .-. . ;: ,� � -�. :- £ _ �lender s Name - � ,: _ '; °i °; - - a �. fi` � � Lender s Address ' _ � " I`erti�y that I have�read�his appiicafion and slo(e rhot tFie � � _ ` - - _ - .=�, . , _�_ _ ,. above mformahon�s[orrect I agree to tomply with al I Cou�ty �� - - -f- �� 'b�tl nd cesand State lo..ws,regulotingplumbmg�,and hereby � - � � - - �- - � - - � � � � auihorize�rapreseniptives of ihis-County!o entaf opan-�ihe � - -� �- - � - � . � � - .- - � � � �a6a e ment oned properly for mspection purposes. � -`-� - ` � ��- ' - � - ,� c SE'E RfVERSE FOR"EXPLAHATORY Le�NGIIAGE � ��`�A C�� �=i"i_�'� _ � Signaturp f P rminge_. �:_. ...Date . . . . - ,.: . ,_ .. .- . . . .. . . .. � ��- '. `��_-._._.�.: '.,,�_ .,,��,.:-:..: � `- �����,:,� -` . , _ � -- . �`�,�sa. ��1 :�s��.'�.a,. - �-'-. .;",�� �,', °��:���� "����:�������r��' c��������� �r� , _�.' � �, ` 4�.�A�s � . �...� ?nl� .:�Ns� .„��s{�yaruR : INSPEfiOR 5 P�OTES^�� _ .•- �+ . �,..� r7�'�iv.��`1��CF L'C�L�QH �2 r : . � �-�'----'--ai -�--= ��,�_t:a�� �QC's,� �`'# 3�?� c� a t t .., --L�CER SCAB W6RK I r 1 s$? tf . � rnr^p'etn,.,jJ*i _: 1.0 `` . 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