HomeMy WebLinkAbout0966A (5) � � 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' � � � -
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�.'. 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'"
�-" �� Cerlified cu�y is hereby(urnishe .- - 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��
s - . (This secvlan need not be comQlatad i#the wark Invalved 6y ' �SHowee �_. � �FIL Z L � .. �,_._....__�_ .��
� _ � }he purmi4 iQ for one�hundred da0crs($700)ae less:) �` IAVAiORv f �y�,�gu AODRESS �
� I certify that In 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'Compensarion Laws ���-- - ?�;�,:
� � . . � OISHWASHER . ��— �_.... Y� �._ �,,
. COMRACTQR
� �
� � Date App��:an! � �CLOTHES WASHER A�DRESS
$ NOTlCE�FO'�A?PLICANT if after making;this.Ceriificaie of . _ -*�"���• -�'��'�� ��'.�
� t enpktifl, ou shauld become sub�ect to the-Werkers SWIPAMINGPUULRECtPfUR ,
Y !'ITY TEL.NO,�y p�,jr
� .ompensofion provisions of the lobor Cade,you must forth — /�a `�, .s^��
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 chack fee 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 the 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 hereby affirm that 4here is c tonstruction lending agena y io. ' �. - _ - ��
� .�
�-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 infa�mat�on is mrrect.-I agree to comply with Qil Lo�nfy , - , � ��:
!� �� -.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 ?
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