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� �WORKFRS�COMPFNSATION DFClAl2ATI0IJ'' '•��'�¢�. �:�: : � `� + �.'' ..�:�}.: ���..:�.; h Ft.: .�,. . . ::. '
,� '� hP��tiY'�f��m�t�� � ��,��c cEr�FmtP�of conseM to�scl(+� �fi;�,;�,,, , 3: � APPLICAl"ION�FORSPLFI��MBING PERMIT � ,
,� � ns�re,or�cerifiwtc of Workcri Cornpgnsoliori Insyrnn<c���,CE qi�(RIV IOiNi� ' , .� .'. :. � �, : � 1 � i 1'
i '���or u cenif cd copy thcrcol(Sr.c 3800,lob.C) 1.� ]' . . �'; , � �, r.? °t ���'�.
� �7 t�� ��y , ES BU11�IN`BUILDING AND SAFETY � ' ` ;
,� ;��Y N�'�w o�r�r F v-- -_��; r I. xc� COUNTY OF LOScANGEL , � � ,
. .. —_ �n �----� ira '3 ! � ;::. ��.�,�:;�,.
CP�hIIAII(U�JY is hereby fumished • � � �t
� P ___ OR/�Pc C F(�FILL IN(PRINT(1R fVl�) —_"_ .�1� �/7 ��D/ 4
Certif o f ith ihc co�i� boil�J�n �J,A /J
� ._'� �y.���+ i� y [�ina e� _ ADDRk55 %'
� hoi c n YJ' � NUM91R HXTURE(N21iFb1 (2 FEE �t�:'
� ,/..f/,.,'�--- InCAIITY
��Daf�e✓ efln` ____ _.__ WAT'cRCICISET � ' — _ — -_- —______' ..
NtAR�ST ,
! CERTIFICATE OF E PT N FROM WORKERS' BATtITUB CROSSST. . �.�'
C'�, COM SAL! N INSURANCF --'_-. "...'— " - -" ' --- UWhcR ��
(This secfton nee o e complefad iF Ihe work�involvod by sHowfv /�:_� �,z __ ���t .,�_
� - - — ' -- --- ..
.::;' �he permit is F e hundred dollars(5100)or less,) �j� �1 LAVAfOBY � 1�"C� a n n R e s s ��
..i I ccrtiiy,fhat in Ihe perforn�nn<c of thc work for whirh�his �.� -.. . -�-�--- .___ ....._ ' -.-- -._..._._----.—. .� ...;��
pr.rrnil i.s issuid,1�sfinll nul ernp�oy nny person in oriy mnnncr�:; _� SINK Q'L�UTY , TEL.NO.
50 O5�O bccoine sunjed�o the Workeri CompansaiiOn Lnws �� f)ISFI6YASHER /) /
: . ; . ' . : �p, . _...__ CONfRACT(�R..�� C _, F�� /.
DNe` � A Icanl � '`��6•'��'r .
,i� �--- PP � 3 ' CLOIFi15 W�SHEN �� —,/ T �'
y NOTICE TO APPIICANT: 11, nfiter mnking ihis Certiticalr o{ �;. - " --- '- -' - ADDNESS i�(��G=-�. .f,�.�,.�e/„rj'lVj+Iz � � �' ",
`F rr pl on you should become sub�ert to the Workfrs ��: SWIMMiNG IYY,71 REC'EPTC)R -��-- � —� '
� �Compe sc�t�, p oyicions of ihe Lnbor Codr.,you rnust foqh {�y. � - �"'- "'' "-- ��'Y `' > TEl NO.ra c t�
iowN saawK�Eksrs;ern ��a iv��•'o�zC��J l� �d:l /Si/O '
I � v ih comply wi�h soch provisionx or tnis p=rmit shaii bc �� ____ �"'�—
1 ; � - _.-.- . STATE IIC
�de.cmea e�okPd�. .k WAII R I IFATEu I ICf.NSE k0 :✓ v��'p a nss C'.�' �(
LICENSFD CONiRACiORS UCCLARAT'Oh t
�� ` .� X ...... . .." -"- - - UISiHIQ Nq.— - PROCESSED BY .
�I f ereby affinn ihot I wn I u=nsed undrn provisicxis oi Chapter 9 � GAS SVSiEIn OU7LEi5 �/� q �
..
..—._..
l
. fco r r en<my wdh Sectron 7000 �Drvm�on 3 of the 8utmes5 � OUitF75OVER �-
� 'a d P o fessioiis Co de,an d my i�rPnsP is m fv l l fw�c ond nff�ci 5 Fi R SYSTEM1I _ __ _ FINAL ' S9 a
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a
S!70$S �'� (N +�' ,,�" /`/ �� ,5 .,E , _.. f U narr i .; �%" VALIDATION o
.l reqse N�mber . _.__Lic.Closs__ ,.,'g�t ""_ 1�._. � ' _'__ („y ,..
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con�r�uo�— _—o:��t•_
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' 1 bm exr.mpf undnr SP.: _ ._ yj -....— _. ....... ..- -•.. ' HI
.. B.SP:C Eor Ihis reasqn_ '4. -- �. _ . .- - - , �.'.:
` '� --- °• Pian check fee
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---Uare;:_ < - _ ' - ---� .
. . '_-- _ — ' ' `'.:
f':
� ' PLUhM1DING PFRMII ISSUING FfE$ � ,.'�-[) i::
' - Siqnaturn. _...__' in __.__ ". .__ ._ ,�_ _ .
� � ----- — �rt TOTAI.hEE fI .���z . :y�,
� �, �. __ �__..—_. ... 1 r � ,�1 '
� I lon cheik npplicm�d �r.
SINGLE FAMILY ;*� . , ��
t ; HOME OWNER•6UILDER DEC'ARAiION ,� Nc e ___ _ �
� �I here.hy affirm fhal I nm zxPmpf frnm+h�Co�drotlor's Licrose _ —- - -'_ . I �, " I'[i �� � �.�,�
'law for 7fir,foHowing renson(Sec�ion�703L5,8us�ness and 1 �
�Profess ons Codel' Ciry Tel.Mo. � o � �i � � � '
��.;
F� ��❑ I,os,ow icr ol the propc.ly,will do the work ond the -.. .^--'- " � � ,
strur.ture s no1 infended or offered�lor salc,�5r,ction � ► r � '-������ � q���;
X 7044,Business ond Professions Code�, � �� . �
�a- . • CONSTRUCTION LENUING AGENCY � � � � ;
� �,I horcby nFf rm tFat iherP�a cona7ruUion Innding ogency for � . :
'�he perfornwnre of Ihe•Nork f�,wh ch��h s perr i t is issucd y� ���;
.(Ser 3097,Civ C.1 , ; . :�+i
,<.q
':'i ' k."�:�
..�Lender's Name_ . , ,i
� '-Y-- � ���:
�Lrndcr's Address_. �d . ;
��'I cPrtlfy t1�a1�I hr ve Mtlti tltls appliraliO�i n110�lale tllal Ille �' .
. above mfor n<�Nion ic corroU.f ngree to cornply wii6 all CouNy. ��,.� ► . }�(.;i
�ordmnntea and Sluln lo�.vs rerjulolin�Plumb ny.�nd herr.by �..� .. � :,�r
,�ut6vrve representnhvrs o! Ihis County b entar upon �hc-.'s;
i abovr Eie 1 fW�lnSpnclion purposes. .+ . .k;
'��; SEE REVERSE FOR EXPLANATORY LANGUAGE
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