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Home My WebLink About1609A �� WORKER3`COMPENSATION DEEIARATION.- . �� .. � . � APPLICATION�FOR PLUMBFNG PERMIT�� - - � I hereby affirm ihat I have a cen f�cate of consent to self 76n667a - �.. insure;or a-certificate of Workers'Compensnfion Insur�nce, - CE 817(REV.10/SI)--�� - - � ---�- - - �- - . - -- . � . or a cerrified copy thereof(Sec:3800,lab.C.) COUNTYOF LOS ANGELES BUILDINGAND SAFETY - � .P❑olicY.No. FiQRd2F,ri Company f;r-�Amar�inan . . . . .: _ . . .�. . . _ Certfied mpy�,is heraby_furmshed ��y f`� � . ' � FOR APPLICANT TO FILL II�t(PRINT OR-TVPEJ BUILDING _ . []X ce�r�f�ed�opy's f�lad�;�h rhe�o��+y b�id�ng��spee- nooRess 3551 Hawkwood Road fion deparimen}. �- - - . . NUMBER FIXTURE OR ITEM �o ' FEE �OCALITY �� - 2-13-84 LeaVerton wnreaaoser r--- Diamond Ba Dpte Appli4a�� - NEAREST � - � � - CERTIFlCATE OF EXEMPTIQN FROM.WORKERS' . .�_ �BATHTUe . � �� ,..-� CRO55 ST. - � ` COMPENSATION.INSIJRANCE � sYOw[-R - l ^a,., owNER � � - � (This-see�ioa need:not be compfeted if the work irwblred 6y� .: . . -- . ... . . . . - . , - i, . fhe permit is for one hundred dollgrs(5100)or less:}. � � LqvArORY - - MAIL- _ _ � �=� i certify that n.the performqnce of the wark{or whlch this nooaess 2Q82 BUS�111�SS C211t2L �DY. permit is issued�,-I,shall not employ any persort im m�y manner � SiNK � , aiv - - ieL NO so as to become subject to the Workers'�Compensation Laws. - _ . . � . �-iXVZne . 927�:� 833-218 . . _ OISHWASHER . r�/' r' CON7RACTOR. _ �- Dafe� - Appficant' -- CLOTHES WASHER � � qpDRESS ].(']zZ jja1e N" "CE-TO APPLICAN7� If, atte� making fhis CerfificoTe of _ �{.y�nryMlRiGFOHC�E€C€PF�` - ` " - -- '� — _ _- �`� E pfion you sMbuld become suLSj�d:to 'the Workers' _' ��- ' " � ` ` - t ,, � �-� . . . y-L p �u�'Q _ . �i, - � .... .. , � - . �' � U � � YY#. r�� . . . _ 1 � � �� G �y �..a' - o _�` � _ .. .' �.,4.� �� . . . . . . Q Y � � �/'��:�u�,� D� �� a�. 0 Jt Q>.�£ � ' QS'��y 09 ��"Y.� � f � . . � . . - y'�- q�Jy�^v &'�E4. y w di p� ` .� ��a.'y G . � . . �m }.Q � C'�� an � �' � G � � ` �wg � _ ' - � . . � . . . O� } p� a �O G £'� v 'y" `n .�4y 9t� �' ` . ' ' . . . . � G � � c-n g a, � � a a as c °�o�p� �� • o v, . p o 4 � u n�i � �n �' .S8 d � G p ?y � � n . � - � .. . �:� � > � a ° � c� �� ;roa� a � o >-� �' t 7 ra ro a � ar �°� � �. e� �' � ° � �,s �?"O ' 1, n � � O s'";r E. `�"�� ' � �' >a� a°a�s �� 'a.'sa es � Q �� "- � ` u • � F „c., c�-� ca� � �� g . n� �� €� ,n a !`, o o � _ �4 ,c�,r a.� a �o � ��y � o ct� � , p� c 9- . �a v� qg � ��, � g �� o"� P Qo ��8� $� �� `! °-) � ;,;- _ � �.�,yM x o �y y g � ,� a � -a.� o � °y << ` �� ? �=� a� o '—" E �"' ° � w-°o ��a w� �'` g. � � ,�v o� w "`--cssa, wa� � � c mom3 �-� � �. °"" � � a° ou �� e °�y� o � ^m-� ..� u�� °"m� y"� ca x . c.y �y � � — � a� G �' = �-o �:._ . o � r� �. u� @ � a� � a- a �} �-;' is s u � `�� c •�� e 7 v��, �� .a .' � � �y ` \�� -c a m t� �a � � y, � ��o a.'�!� � p� '�0 6 � �� -e'�u :o,� �s�� s�;�� ' � 'a '�. `�'.c3 E7 R p y�q ,�, V�'ds ta-y y O�.iG t3 � `� � s � � 3� � r� L��u <vs.'e� _ is � � � ; '� " l o } � �-�N a a � �� y._.. " '� -T '�C C ai� b' 6a . � _ . . ' . .d �.� � ffi e� � t��,N..w r . ' k� _ �qq]] � � . - .'� U � ro `O �� . . . . . 1 �zts � � '�, , - , ; ; � � � � V 4 , � �;, tt � a 1 � ;. � �t �� 3''� � � 1 � � ' � �� , � � � �� 0 � ��, � �� 1 � � , , � � � � �'w w \ , 1 1 � � � . ,dlS� , � t , }��} � � , . � . .� � . - �Cc�� - ` . � . � . , y � � ` .� `,,1` � � g � t � x �� ` � � �� ' f � t � , � , � '`; � � � � �� , � , ; , , � l ,, � , � � ` , , `�� ` . � ' t � � ', ��. , ��, s �� , `,,� � � � `1 �+ �`� k � , 1 � 4 � � c , � � � � a � � � � � � �� h � � , � � � � `y � � ' � 1� � � t ,4 � � � � `} t� � " ' ' �� . .� �� . t ' ` . ., . '.G-' - ' � . . � d , . ' a � �(O� �.�.. y . � .. . . , . - . . .. . � ., '±, t . ',.'1� '�V �` . � �:. � " . .. . . � '� � . Y'` ' . � . , .: . .. . ....-- . Q��. .' C \ ' . . . . , . ' . ., - , ��R.i '�` ' � '- a . . .. ... '_. f . . . _._.�' d . � �. O . . . ' . ' _ �� P- ,. . . . � � t � � � �w � �' �� p � ,y �r .O z.� .`z '..a�' U �Qj � } "� .]4 ' .. �m � j 2 �}�� m Y ~ �� 2� . � �� o. � �y �a�d i� 'u' _- R � g� N d�d Q S,�.a � � Q �y, y a � � -