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HomeMy WebLinkAbout0966A � � WORKERS,COMPENSATION'DECLARATION��. � p�T � �` � ����A qtw,/� P�RM�.IT ��-� -aby u,���.. ..,. ! �a:e:; ..�r�i�tate o wr,san�f L � ��� 76A667A�-. �����iW"��� T�__ -.r.?�=—�-!tl`9 , —_' s���� insure,or a cerhficate of Workers' � � � - ��' �.'. Compensation InsUrance � CE 9V tREV.�10/81) �� �.' : � s� or a ce.�*ified c�}o/pyr ythe�Jreof(Sec 9800,�nb C) �Q��TY O�LOS.�!d�ELES �al�tt?Ited/^v RRFC75AF€FY '�g . ...:Pniity N�ldm��77-_Cotn.pany:,� ! _ : � ..� .� ��1`d�� .�ry :T'" �-" �� Certified copy is hereby furnishe .- - 1-�, FOR APPLICANT t0 F�LL IN(PRIM OR TYPE) �UILDING A , , � - __._ ._ . _____._ . — ADDRE55 sq��-'J�.✓ ��,1� � i / ::; Certified copy is filed with the couniy Uuilding�nspec E —�� � ' � � I�on deonrhneN. `�'F NUPABER � PIXTURE OR ITEM @ FEE I � p ?,�, g// LOCA!ITY Jf`�����. ' � �+ - Gy--I t��j .� 6. � WHTER CLOSET j�> � bd. >� - Dote Appli;nnf ��____� ___'_. �NEAREST . kq.�. � CERTIPICAiE OF EX£tJ�PTICN FRO&M1 WOR RS' � CROS5 ST. I BFlTH TUB �I"P� ;�' �--�- .� CON�PENSAT{ON INSURANCE , owNER � " � fi�� �SHOWER s - � (This section need not be comQleTed i#the work invalved hy ' "'� �Fii t-e� � ' � }he purmi4 iQ for one�hundred da0crs($700)ae less:) �` IAVAiORv f �y�,�gu AODRESS � I certify that.�n the pz�forriance of ihe work far.which this �����-- —��--��- j � ermit is issued,I shall not em lo ari erson In an manner �SIN� Orr TEL NO. �,� P P Y Y P Y PV"'� I'"" d.� ����npC> 'sX � � so as to become.subject;o the Workers'Comperasation Laws d' OiStiWAStiek . ��— �-.... r� ��? . COMRACTQR '-� � � � � Date App��:an! � �CLOTHES WASHER A�DRESS $ NOTlCEt,FO'�A?PLICANT if after making;this Ceriificaie of _ . ._ -*�"���• -�'��'�� ;;�. t em ktifl, ou shauld become sub�ect to the-Werkers j SWIPArtAiNG POOL RECEP70R � � - .ompe.nsofion provisions of the lobor Cade,you must forth — ��TY Y TEL.NO,��!"8�+`�', �,�' lAWN SPRINK�E2$YS?EM ,: aith comply with such orovisions or iMs.permit.shall be STATE � p/�eq IIC. ,ij� e. eerned revoked.� � WATER iiEATFR LICENSE NO. �VY l� CLA55 (,+ �� ;� LICENSE6 CQNTRttC7pR$pECLARAT!ON - --+--- — D�STRfCT'NO. .OCfSSED SY �� ��: I here6y affirm fhat i am.lice�sed under pro is�ons of Chaoter 4 ���GAS SYSTEM �0117fFTS ,�� _— � . ?.�,' �- (commencing wifh Sectlon 7p(b)of Divisior 3 of ihe Bus�nssz 011RETS O�lER t2'�"'�� ��� �and Professions Code,and�my license�is.in fiulf force and effect. 5 PEH SY57`M FIt�AL �+,�� �' Vl4LlDATIOi� � ��..- ��� � ��is "^f DATE L�� ��^� i� �.� License Numbar _.Lic Cla �:- � �y ..:.�., -fINAL ,�.M d�2�� � : -�Coniracior „� ��ate � �`!"�� _ � �� .—._.—__.._ _ � gy 6.s� . ar��g �� �❑ I arn exernpi under Sec t � � __ - �� �. 't�.r � a3' ��.__ t s?�. � t�xr�.c.fo�rt,s���S�n___-__ plan check fse t , � ��. � � .. Date: —..-.__.__ . . . PtUMBHVG PERf�M1IT ISSUING FEE S a'P� r �-��' � �, Signat�re�__..�� -----�— � �� . -�; t_. . - �TpTA(.fEE . � - -: ii c ��. i� � � � � Plan chAck applicont. - . . % � ._ ' SfNG1E��MILY — , . �. . � `� ���., HOMF O'JJNER-SUILDER DECLARATlQN -- :Vame �� ------_..__ __.�.__ � . . I hereby affirm that I r�m exempt from ihe Contrador's i icense � Address - � � '?w for Ihe fo3lawing reason (Sec`mn 7a3'S, 8usiness and _ -� -� ��ofess�ons Code):- " City Tel.No. - -. ' � ,:' ''7 �S a _ :.L_l I,as owner of the property,will do ihe work and ihe � " �� '��; y�.�, struUure is not intended or oftered fer sale(Sedion � � �, . . f-` 70-04,8usiness and Pro*essions Co�e). � � � - `, � .- .,� �; - . .. -'�t a .., CONSTRUCTION LENUING AGENCY � � ��,;�;+ a',� .I here6y affirm that there is c conslruction lending ogenry to� ' � - - �� � .§ �-the performonte of ihe work for svhich this permit is issued ;�, � (Sec.3097,Civ:C.). �� � �'- �� Lender's Name - . . �"' �"�- -Lender's A_ddress � � ��� ��� �� 1 certify thot 1 have read this application and state thaf ihe - - '�! + -- above infarmat�on is mrreci.l agree fo mmply with Qil Lounfy , - , � ��: !� �� -.ordinunces and State Ipws regulpiing Plumbinc7,and herebv . ����� - . - � � : . � �� �.. au rize representatives of this County fo enter upon the � .� � - ^Y'* -a ov me � ned property for inspeciion purposes. �� . , . �;�� � _._--- SEE REVERSE FOR EXPLANATARY lAPlGUAGE ? S �( �� �'���� �;. 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