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HomeMy WebLinkAbout1094A (9) -��: t ,S,r... 2�� ,..�,� .�S,w-'�;:.: d z.� �.:i, r .�U i#,,,��';P.Y4^€ ,Ll,� kh.: :• �• �4 :?�, T ,J . ... 3 � WORKERS'�COMPENSATIOt�`!DEGLARHTION �� �,��'�2� � G} � u '� � ' ! ���� s � �—��� ��.� ���`�AR�PL'F�`�lTION�F�7R�f�L�U1V�81R���PfRMIT � � , ��.: �� i �raffirm 1ha�t I have�p certificate�oftconsen�to�.,self 76A667H '" � . ' � ." E`. , ���, ���'`'. �'��' 'r a ceniflcote of Workers'Com ensation Insorqnce,� CE 8V REV 10l81)j • � ' �� -es � i � - y�'. n,,, t�� P ; . . , �o . . - . ' A �h.i. �67 'N� :� �!Fv � n *�o� _erti9ied co thereof(,Se.98 ,1a6.C.) ��'�? � A � GOUNTY OF105 ANGElES BUILDINCi PIND SAFETY k �T �s � � °� �a��3--S�� �. � ii;'Pohcy No. Company � �.�5, ..� , . ' '. - � �� � .�'s'�'..��'�'� � i f��.'�, . ��y� CerYfied copy is hereby furnished. . -+'� BUIIDING ' FOR APPLICANT TO FILL IN(PRINT OR TYPE) �ia� � �2� ADDRESS - i M�� � �� �Certlf(ed copy�s filed with ihe county building inspec- t� �✓ �'��, �. t i NUMBER FlXTIJRF OR 17FM L� PEE ,i �'���.lion deparlment. � '� /y, LOCAIITY � .,�- ' A�_ ��, � .. t C� . � . . � . � Z. WATFR CLC1SEi � �V d�'T �.. t ;Dalg' ' Ap'plitant NEAREST Jyt i „� � caosssr. L-�121�it�i� qJ�� �� � � = CERTIPICATE OF EXEMPTION FROM WORKERS' ;� BATH TUe q� - t,� � '� � COMPENSATION tNSURANCE � owNeR L� �� ��v�., '4 �� �SHOWER �- 1.I i.�i '�;(ihis sactfon naed not be compleTed if the�wurk involved by'+t' `' . � "1ha permit is for one hundred dolters(s100)er tassJ � iAVAiOev +,.�� �"� O DDRF.$$ i`j�� �.t/�ag y�$(,�• �� �� ,� �a""`I certify�hat in the performonce of ihe work for whick rhis��� � � �T r � SMK — � CI?V - �r TEL NO. ,}�``r � �,spermii is issued,I shG��not employ ony person in any mqnner'- ��a� �C1 Gy?}2 (ji tiT C' ' ��..' 5 ,,.,so as to become subject to�the Workers'Compensation Lows.�' , [ � pISH W ASHER CONTRACT�R ` .1 Z. C.,. -�o i ��a. .��; . ti `Date Applimnt �' CLOTHES WASHER AD�RE55 � / ��� �� ',:NOTICE TO APPUCANT: I[, after moking this CertiLmte o4 � - - �D L�� ���� ���� � � �t�Exemption; you should become subiecl.fo the Workers' SJJIMMING POOL RECEP70R , �� 4� r Comp9nsalian provi5ion5 Of the Labor Code,.you mus�4orlh-�� �AWN SPRINKLERSYSTEM C�Tv �i+S`''4S�r3�� �j/ TE�.NOL/��,+ ' / 'n] ;._ �,�,with comply with s�ch provisions or this.permit,shall be � , S7ATE y / � UC. � 9 �' � � deemed.revoked � �� - � �. . W'ATER HEATER � IICENSE NO J �l,.o C1A55 � _; �, LICENSED CONTRACTORS DECLARATION - � � � O� atSTRiCi NO. Op,[t CE55E0 BY � j s��''�5��;�I here6y offirm tha�1 am:licensed under prov sions of Chopter 9��. 0 GAS SvSTEM OU7 (��` - . � �1� 1���.Y��\Q—... . �. i s'�,`�,tr.�commenung with Secfion 7000)of Division 3 of the Bus�ness�'; GUTLE750VER `j s � ry'� �,��F'and Professions Code,and m license is jn foll fo¢e and effecC 5 PER SYSTFM v FiNA� VALIDATION � I �h;��Lice�se Number ��r�t`/�� Lic.Class_..'-t'"—�� � 1-' ("� DATE � a�,�. . , s; �..�. I��f �,: � � FINAL � � '� � �.`Contracfor �l. �gsr. (a��. Date �r 7 ) �. ��:. BY . .,. � :� ' i � � ��. :� � ,��fy �'��� i am exempt u�der Sec. � � �� � � asg ;� F y� B.&P.0 for thls reoson . � � � •.: rx�: 1��, Pfan check fee t .r' � F�,l �Dote. . ; NLUM6ING PERMIT ISSUING FEE�y l� -�� . .�, < 7 +� ; SignaNre�'C.'�s'�-�..��..�....� 4;:, �' L�r� ' 9I. }� �':� �" � TOTAL fEE a � . . y�, ��. . 4�� Flon check applimnt � � ��t � SiNGIE FAMILY °: � � � � HOME OWNER-BUILDER DECLARATION � Name � 1 here6y affirm�F�at I am exempt from the ConGacror's�l��ce�nsV �+". Addre.ss � r � : Law for ihe f II.�.. --„'r �`=cyo^?„ • � I ^ Professions Code)� ��,�^�^ y n�'J V �;� City Tel.No.� - . �1 U 9'4� + �, �� t., i,as owner of the ro ert will da 1he work and ihe �a � 1 �� P P Y, �. . �� �;%o.m.• n a rj ; � sirudure�is not intended or offered for sa�e �Section i Y� 7044,8usiness nnd Professiong Code). � � � a m(�d.�Q '� ?(M ! g{..+��'t � WNSTRUCTION LENDING AGENCY . � . �, a ,�/��r�y u .� 7-��I hereby affirm that there�is a construdion lending agency for � ^ .'�rhe erformonce of the vrork for which this ermit is issued , "�se�pso9�,c� c.�. . P P, 1.1 9—.8 4 j �; � ;.Londels Name . . � " j ` . � r�" -�.Lender_'s Address . ' 4� �� I cenify?hat I hove read Ihis opplirn.�er and sta'�tfia'the . � . x �i above information is correct.I ayree lo comply with all County � . . �� ��ordinances and Siate iaws regulating Plbmbing,and hereby , � ����authorire representoiives of this County lo enler upon the � " i:�above-mentioned property for inspeclinn purposes. y � ���� SEE REVERSE FOR EXPLANATORY LANGUAGE t�� � r� C ���ignoture Permittee � D e ;,_ . k T. . c �I� _ � � �: DCi� D ��Ni� 0 � cpil0 0 , ,. . . . m v" < m � $ rr� ��S �I �..� � )y A I () -Ni z -D-i Z Z '� v'I D � � AA� ' r IO T� TI � ,�}���I� � � X m 1. W`�'O S . . � � i �� C D: Z m D� � I T � G� � , o �, � G . [ — � ' ' ; � z � � i° rn v I � i �� rn o� � � �, ? I �� � Z � � �m � � O � � G1 Z . D �� i � ,7;. .... ,.,> � '. . . .... .... . � .. ,.. . . . .'. � �� .�. . �. �. . �� .. ,. .;:.r :.. :... ... :.::..... ��-�; ... . : . - �. ... . . .,.. � :� . � '.�� :�- . , n �� _ . . . , .. .. , . , :. . .:. _ �..:� � . ... ,' ' �... . . . .:...�. 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