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HomeMy WebLinkAbout1625A ;, ,..�, ' .. ,'"; ,' ', � .�.v ��, . . ... .. . .. �. ,., . ..... � �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 � - ' •_ '_ • . _{ . a S!70$S �'� (N +�' ,,�" /`/ �� ,5 .,E , _.. f U narr i .; �%" VALIDATION o .l reqse N�mber . _.__Lic.Closs__ ,.,'g�t ""_ 1�._. � ' _'__ („y ,.. r con�r�uo�— _—o:��t•_ } -- -. _..._ __.. oY ni. ... � - � , --- � ::. ' 1 bm exr.mpf undnr SP.: _ ._ yj -....— _. ....... ..- -•.. ' HI .. B.SP:C Eor Ihis reasqn_ '4. -- �. _ . .- - - , �.'.: ` '� --- °• Pian check fee � ---Uare;:_ < - _ ' - ---� . . . '_-- _ — ' ' `'.: f': � ' PLUhM1DING PFRMII ISSUING FfE$ � ,.'�-[) 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 �.'�� ' �--�i,��. < c .i c� _. _— ; J1/'1t�IU rt o�8 I?Mi=.' Uole. ;',�n ' yg ..� 1 tdr ,! .4; �� ,.;�... . . ps�h.:�3.:R'[5'.�.+1.'�... . ' . . � r. � _ . . . . : .� �.. .�. .. . . : �_ _ _.. ,. . .. � � . .� . . . . . . .. .. _ . . . � ,�x�f ' z I �;n�4 c� `"��" �, I n C' ) � r In�} -Vi uDi l� C:j � �'[': 1 � ' ,I� I '�•� � .' yl {���0] L C.����il q 1 . � � � C � j � !I ' �>� f ,� �I�i�I?`�i^ ���, �= . , i i � � � f I � i I �7I IjC'T� f�I'��I.z�r� r��x I I ' . . �. __ �, I � � i � 1 i I I1!I FC�A I IfZ �C �' �u IG)���D � ��� � � ! ' fl � � � . . � . . �— ;� � � ;��� ;��AI � � � � � �� I I I i_ . 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