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HomeMy WebLinkAbout1729A __ _ ._ _ ... _ �.,�.e��:;K� -��,. .,. .,�;P,... � WbRKER3'�COMPENSA71bli(DECLARAT16N �" M � � ������°��������P�������rT _.:. I hereby aff m ihal I�ha e o certifimte of conseN to self zo ooze oPw 6/$? COUNTY OF,COS ANGELES��� '�C5 � � inwre,or a�ceri f'm(e,pf Workers''Compensation'Insvronce 76A657A' � . . . _ .. . _ ..���.�,,..�....n.,...:W�...:.. � �or o cer+ified copy ihereof(Sec.3800 Loli C.l _..,, . -"� �p�',b�P�J$�t��IdI�K�, . . . � Policy No..- Company - � _. . �.:... . ....._ ._.:. .. . ��.,_.: .... .... ... ...... ._...... ..., �:.:�.: ., � Cerlified copy is hereby f�rnished . � � �� gU�LDING �/ -�. .:; .: .�� , .- �� FORAPPLICANiTOfILLIN(PRMTORTY7EJ q00RE$$ � Ut� Nt- . .. ; ,. .. __ ..... Certifled copY'is�filea wHh ihe county buiiding�mspec- NUMBER "rIXTURE OR I7EM Cru FEE ' .. tion deportment. ' iOCALITV �� ' � �� ... . ' .� . WATER CLOSEL . � . . Date APPI caN � NEAREST GERTIFICATE OF�EX�Ft(771QN��Ff{�FR�'W6�21�ER5 . ,..._ .:, gA7H TUB� . � �, , �j ' ST.-��•._,--.. .. . � � :�� �- � -- COMPENSATION IN.SUI�ANCE ��� � � � � . �y OWNER f j !'/-� � .. .. � ,,. ._n..: ....... . . SHOWER �iJ _� ��Cf�P��� . / V�"'G � (This aedion naed nof�bu completed�t�ie work iavolv¢d by���� I )�� �... the permlf is!or one hundred dallars(5100)or leas.) `i LAVAtORY � � AD'�RESS� �� y � " r •[,--�"`" � I ce t fy that n the pe4fo mance of the work fo which ihi; � � � permi� 5 issued,I shall nof oy� y person in any manner' � % S��K �^ � OTY� '°.�� ���,�.f�y�,!t(�. TEL NO. � ! ... ... .. ......... • � :so as to bemme subjecr o the Worke 'Compensarion aws oI5HWq5HER -� � � �� � . CONTkACTOR � �iC+' i G-�y'� : � Dote� '+-" ��ApP�cani � ! CLO7HES WASFIER � �i ADORE55 ' �^ ''-��- 1��� � N0710E TO°APP�.ICA'NT If o(t mak ng +his Cerr cate of SwIMMING PODt RE�EPTOR"��� �� -��Exempf on,��you shou(d 6ecome sub�ect to the�Wa kers' ��`CI� � ��' TEL.NO. ,_?�`� ` Compensalion provis�ons of Ihe Laba+Code,you must forth- LAWN SPRINKLER 5YSTEM � � - ` .��with mmply with soch provisions or this permit shotl be STATE � ��deemed revoked. WATER HEATER � � - LICENSE NO�.�� ~ ClASS � " � - � � �TICENSEDCC1NTt2AC70R5��E�CLAkA7R3N�����'�������� �� oiSTRiciNo. �"� rR ESSED�BY�- _ � '. I herehy o.ffirm�hai�1 am licensed,under provisions of Chapfer 9 GAS SvSTEM OUTL`ei5 �.�(commencing dh Section 7000)of Diu�sron 3 of the 8usiness OUTCET56VER��� ��� � � � � � � and Professions Code,and m I cense is m full force ond effecf. 5 PER SVS7EM FINAL . r - .� onre ��% YALtDAT10N p �'33 g�:�' ' �� aas�.�— � . L�cense Number' � /� ' — FINAL � � ' Contractor��t�-`� . �r�'��' Dpte ,.' '" ..— . . BY �, .. ❑ . �}' n � � U .. I om exempt under Sec � p.,1 .� 9.8P:C.for �s��reoson `��- � � . .. .. . . .. ... .. �� -; Plan check fee � , - Dote:�_ pLUMB1NG PERMIT i55UWGFEE 3�� s(� �(� � �-. . .Si ture��?L���[� . — _ , � TO?AL KEE � �, � � . . � . .. �� � � .. . :�'�' Flan check applicant �... , �.i ., .1= " . . .. .. . -. , .. . : � .� .,- � � ,SINGLEFAAIILY � . � . � �HOMEOWNER-BG7lbEltDECCARA'fiON` �� ��� � � Name . . . _.. .. .... . .. ._ _ _......., . ._ .... __...:_„.::,.... � 'I herehy pffirm th6t I am exempt from the Con�ractor's License� Address � � ' '�(.� � • G .� law for�he following reason (Setlion 7031.5, Business�and �- '' � . .Professions�Code): City . r. ���.n � , Tel Na��...%.-1�'�`} r I �G c F� ' �❑ I,os owne�of�he prope�ty,w�ll do the work and�he � . � � � - k , � � � � � .structure 's no� intended ar offered for iole (SeU�on � ' Op44,8usiness�and Professions Code). : .. ...,_... _ .�,».. �. . .....__ ,... 1 4 -b�,,� > ....., _...._. ....;. _� . :.., _ ,... cousrautno���NaiHG a��Ntv _ _... , �I hereby nffirm that rhere s a construct on lending agency for � � � W m o t,Jr i�,;� �� the performance ot the work far wh�ch thi:permit is issued . {Sec.3097,Crv.�C.). --- ' �,. . . ,,_.. . . . ..,. .. � . �. . ,., . .. . . il�l.c�J-c.�u :.:::' .� ' . .:::: . :�_ ...:. .'. _.: :_-. . .. _._. _ . _ _.. ,_.... � 7ender's Name . ...,.. -,. W.:._. ...... ........... �..,,: _, . . . � �Lender'sAddress �:_. ;�:. ;` .� .. ��. �. . . � � . . .. , � .__........ .__ � _...,._.. ._._..... _.... .:. .... ..._ .. .. . __.. ... ....._ _........ ....:.. _ ....._._. ._... _ . �I certify tho�I hove read ihis applimtion and stote iho+the � � �� obov.e informo��on is co�retl.I agree to comply with all County - o dinontes and$ta�e Iaws reg�loting Flumbing.ond here6y au rize repre'sentatives of�his Counry to enter�upon the ... above ent oned Property for'nspe tion purposes. . >. . .--.-'- ".^.'.'. ".":...""• ..`..'... .. . . -.�... .... _ _ _, � SEE REVERSE Fi3R EXPLANATORY L;ANGtlAGE � .!� f i �—,�—�'� _ �-Signature of PermitteE�•- Date . .. �. . . � : ��� � ;�� . � ", ..� . x.evu.ar'.��ta. .: .. x';'�A� as..a. 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