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HomeMy WebLinkAbout0962A �WORKERS'COMPENSATIONDECLARATION AC'�����YI�� F�R f�� DINV PL�MIT 4i � z:- � . � - -- - -- -- ---- - - - - -- - ----'---- - ' ._ p a _ i hereby ofiirm thai i hove a certificate ofi consent to self . 7hn667A � �;� [� . insure, or a certifimte of Workers'Compensation Insurance, CE 817(REV.tQ�Bll � � � - � or o ce�,rfied copy thereof(Sec.3600,�06.C.) C�iJNTY OF�L1S�NGELES BIJILt3lfdCi AN13 SAPETY ` g - � Policy No.�p�s Companv �� � . - � �- � � �r g o� � �-� . v'BmF'������6. � ��� CPrt fied copy ic hareF>y f��m�shPd. �:��� ° FOR APPUCAN7T0 FILL IN fpRINT OR iYPEJ BUlL�ING �� � � ��- ' � -� � Cert�fied copy i�f led wit�i�ne couNy building inspec AD�RE55 tion de ar�ment. NUMBERT FIXT�RC OR ITF.M Q FEE -�" r� ��r ` �- LOCALITY ��� ��g �� �' .1,� a r,Hra��ose� I�" _Itd�" ..- Dote � Appficant _ �_ ��� _ NeaRE57 � � � ?.� � CERTIFICA�E OF EXEM?TION FROM Lb0 KfRS' � I BATN TUe ��.-- ��-- CR05S S7. � � - ' ; � - COMPEtVSATION�NSURANCE 1 SHO�NER ��� OWNER f� " -� :`�� ' .-.(This secfion need nai 6e eomp�efed ii fhe work imvolved by �. +� , �-- - the permi4 is for ona Fvndred doldars($F00)or Iess.) �.T' tqVATORY ' , � ��' W �+�AN //��- - � ;,g� A�DRESS (� jI certify ihat in�the performance os ine work for which'his - ��� � � `-perrt�it is issued,I sholi not empioy any person in any manner. �/ SINK � .--* � �.^.ITY � TF!.NO.�3 �a � � ��� -�� � � -. so as to bemme subjetl to ihe Workcrs'Compensation Laws.,�, J� o�SHw�StiER .�.� - `g �-:- _ . � - . CON7R4CTOR . � • `.T GaPe � Applicani _ ���_ CIOT-fE5 WASHER ���..- � � � NOT�CE TO APPLICANT� If,.�.after.maR na.ih s�.CertS{icate af H��RESS ,�y°{Q �. �.�,Y���,�,���7 �SWIMMING P06L RECEPfOR � � � �� .ExPmption,. you should becor�ie ub{ect to the VJorkers' I _�� ` � °ensat�on rovisions of the Labo� Code� ou mus:forth � - � TY ��� � R TEL.NO���.��� p y tAWN SPR!NKLER SYSTEM � .`-}comp{y with soch�provisions-or this permit sholl be � � STATE . j ,r-� LIG R �� `� deemed revoked - - Wni�R tiEAicR � —� uCEn�SF No. �O�'[��J ...0 a55 4d ' � 1�CEt+:SED CQNT.RACTORS DECLARA'�C)N Df5?RI�'�N�J- � P OCESSED BY �`'� �I hereby affirm fhat i am hcensed under provisio�s of Ch�pier 9 GAS SYSTEM SOUlLE75 i � --- .. . .�.(mmmencing wiih S=ction 70�6�of Dw s�on 3 oP the 6Usines5 OL'TLE?S OYER � -��"`� ', -.and Pfofsssions Code,and-.my license is in fiuEl-force and eHect 5 PER SYSTEM � � .FINAL l �~ '� �ryd�/ ` ���L� �J4������0� `� � � �-License Num6er��_Lic Class__�_`�F .. ^"' DATE ��' ..�µ� z � �j'tJ, F1NAL �� �� � � . -��ContrQcto�____���.*��Datc e�_��� _ . BY .E''� k3� j ❑ i�m exempt under Sec _ � - . �.n� 4 '9. g - $.&P.C.�ior ihis reason � "-' ��� � Plan check fee ' :' � � • _�_ � Dore� - . . . - .. ; . PLUt�ABiNG F[RMiT iSSUIPIG ffE$ ��"py z' � $ x, 5ignat�re_�___�.i�___ � . . . . �� � . - . iC3TAl.�EF �� � . . ,r . . � �- r � � � - Plon check applicanfi � �n- � �� 54NGLE FAMfi�Y " - = i � "�-i�. � � - HO.ME OVJNER-BUILDc'R DECLARATlON �Name __T '____ . . y�; �here6y affirm that i am exemp!?rom th��Cnntracior's license . . � L `�r the follov ing reason(Sechan 7Q3L5, Business and �. �Address _ _ ' ' �;lions Code): . Gry TeL No. � ��"� t -'-__.('� , :� _ . .. .�. � : L1 �i,as owner of the property,will do the work and fi�e � . . . __ structure is nat infended or offered`or sale�(Section - .�� � _. - 7644,Business and Professiens CodeJ. _ � - � - - - CONSTRUGT70N LENDING AGENCY - � - � � '- � � } ` -:�I hereby aF(ir�r �nal thsre is 6 con>[rudion Iseding ogancy fo- �� - = r�� ^ ;.�ihe pevformance of the�mork for which ihis permit is iss�ed � � � - '� . �..,(Set.3097,Civ.C). - - .. � .��' � }� j �.-.Lender's Name � - ��. a , -� Lender's Address ' , , - - �� � �- I certify that I have read ihis application and state that 1he . � � p -above information is correct.!agree to compiy with all Co�nry = � ���� �; � ordinances and State laws regulating-Pf�mbing,and hereby t � � � - . �; � -. -.authorize represen?atives of this County to enier upon ihe . - � � . � . ,� �._ � �.ab me ioned property for inspection purposes. - � - - . � * ��� 5EE REVERSE F�R EXPLANATORY tANGUAGE � i x . £? � � Sigr �re of Permittee Date ��' '� - � "��-� � � - _. - . - . . _� : � -�r � ._ .. . .. . . . . � . . .. ..�. . .�� � �. ..C � b S G� G� � c �7 Z r � C � � � � C � �m�' D -�'G m m --S < v G� A � Z� �' � � � ;L' j �D � " v� �; -� z � D a „ v r- .,� � 4� c. � a � � O . .., � , y. i C � z A � � .._ T I.-43 an X rtl �N XI � a � - I � 1 � � f✓'t� � �, 'i� • . ,C'8-8� . 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