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Home My WebLink About1609A (9) �� 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' _' ��- ' " � ` ` - ! , �� =� -e �� ;, � � c c� =� 'a � m � � �, �"s , -cr c �, .�:�,aa � .� `vf "" O'Sp-.s.y�, � fu �n � 6Y •--�- . g ' . ' `� ' � D 9- C. .� . �i7.O .R ib.�Yl.4D � t � . . . � � �y � -�'�Qs � '� � 5 �e fl� � �r E =o .. . �n �fY 4 U1' n� v .P�i 61- �!T3 �..,C. ti p:S% . -0..� .G�.b TQ \ . . . . . - . " 'O -C.Q ue N .- 45 c5,ty R^� 6'C' eD ' n"� �\ . . - . . . � -- eh 'Ty "•9 c �'-'4 ° °^ '. -k, w �� >�pv f+ �' � . ' Y� } � f+ � p � b o 9 � � �� o� �� , - ' . . � o �ro � cs:> E �, � 'sa � ,-o� o ° E� a� �` ` a ° � b o� �,� w � - � "� � r, 7 0 � � ° ? °' �,�"`�' �c� y; � �� o �d ��a� as � � �j O �`y'�� `"-�}� � � ',` y °�� tic �s-, m �+ � � � - 'U '__� � } � ffi c �� d �.� ��,�s�. � "n' � \, 4 a � � n � t � � "°"z '�+-r P ° � �'�si,� m-c� e.�' gi � '.�= � ! �. y ^��a � � s o �, �"�-a �° � � -u.� > � � 1 j,�ss � �� ,; :° ��'�„ �g.°"'° s � c� o�>Q�- � °� �' � := �,c �a ?, o-; �3 n "' E �.- °:� �-o € c�mw � � �' � �v y °� '�o v ;c �-a „�, � °�.x-`-' c w o ��"" �"�s.�� t3 6� 3 ''i . . P` �p c a��.:.�.. � Ca 9 s 'SY �Q, ,o��.e.a.�� '@ �°�..� �� :� �- �. . � .�. � , . . ,,t . ,� o o u � � � �(s�,� � �� ,r uo � ��. p � � ; a� � o �, a � vm � r`> e^� � s= � w > ,-'� �' °� t �' G-� ,s -- ;., °' w � Q o> � °' ��'ca 6 ��. ��s-c � �-a b � � ` ;� � r ° � 7.`�-'�v n a m � r�%n.= y oe-.�a �,,�:t�a a�:o � ` � 1 � �a'�°��s-6 m-c� �.a � "�f�s �s:�,°� ° c'E aa 'G' � i � � 3 � � �� ,y�v'?, n � � �s 3 3_` , � a ffi e'a�. �+ c„�� ^��` _ v�a . 7,� m b��m a L Cp�p:.:�Y�^.�t+� . . ,.�,` .�� _. " 00 U j� � ��G,.2°n.,w w ` �.� . - . . �` � . . . S�.�Bs .. � l �; � . . j . �� V �� -_ 1 . . -y 84 . . � � � � t '� �� '`, ` ' ; � � `i �, } �,, � � � �. �� , � � , , � � �.�� \� � �� , , .�, � ; ` � � �s�, ` � `` \ �� a� 1 ` � � � ti \ ti` � � � � � � 1.� \ �� : , 2` � � � � �� \ � '� �t; � � s a , � � � �� , � ; , :, � . 1;j� � � ` . . . . , . . � ; `� a�- :�'� ' �. � t `y't�ys ti �� , �� _ �� t � . � � � � � a � � , �' �` �. � � � ��1 J�; � �� ' . N . � . . . . p, . ��-- . . „O .�` . . . . AY) � . . ' - \ _ ��, � .. � � � . � �� , � - . . ' . . � ` . '. . , . 'N�� , .', q .. . . � . . .. -. . ` . .��.�.. � � . . .. . . ,.---' � ' �.� � � �� . . � . '� � .... . . �` ' � ' ' - i 1 ` � "'� 5� . � . , ' . ; .. . . ..- _ � . 7 � � � r` �� . �'z' � >.1� � �� o �� 7 � .� � � � � � _ pQ o. � "' � 2} r �@� '' � 2'�i _ m 6. �y — c�. a.4 r ` .eu- . 3 �'�� o. � rQ �,;� 7 . � '� G. `� � 4 jZ � � .� � , � �