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HomeMy WebLinkAbout0968A � �- ��,,`d WORKERS'�'COMPE�NSAT(ON�ECLARATION -' �¢ y t h F ��w p���::/ pr ;.�: �;: ; i �• .;;.- r, .:.; t : : .: T . � ��.: �.,t_.._,..�./VY�E..l=�.'l�{#���.191�.:�rl�Rv�'-L��'O�NIF��Q���l.� , ,-�.:w�,. ,�....:.. ,�'k: ;� �.'nereoyyarnrm�rhars� navezd.cerhficare';���orSconserth"to seif .J�.J6A667A�`.' '��:- —' - ''"� `" .:_ -' ' "" �.. ��.".. a, . .� , ., , ,y ,� .: �' , s �. - .� �:.-: �_Y �. q �'msure,or o certificate of Workers'Compensation Insurance � E!'CE 8n(RFV�;tO�Htp`�r�,, .... � ��. �' �``. ; } %, � ; ��or a cert�fied mpy thefeo#(Sec 38Q0,L :C) �� w r ���C�UNTY OP IO�ANGEt�S� ,,�'� �UIlDI1VGiAIVO SAPET�{ � �;� ����� Pol�cy No---���.Co,mpony �'G�- � . � '_; , :; ;: g . r �-�. �«, _ . � .��� � a•��`�.>�.�.�,z.� � � ?,,r ,�a� Certrfied topy is h�reby furnishe ' � � ��� '� " � � `� � ` � - - � HI � �} ' ��' FOR APPLICANT TO FILL IN(PRINT OR TVPE) :. BUILDMG �s�, ! �,� t ,�(�{ �Certifted copy�s frled with the county bv�id+ng,inspec�,?�.�: ADDRESS +a�B ��(c�+�c7c � 7y, ; ;��T��tiOn deport�ea,L ' - +� r NUMBER FIXTURE OR ITEM @ � FEE LOChLITY � � `�� ;v�a�-�0�6 ' �" ,�' wn:itu aosEr �� t:. � a��Date. AppJicani'. � � NEAREST �"�' ' ?'k` - CfRT1FICATE-OFEXEMPTiQN FROAq'-W S" ��� � �enrti rVa � �...o - ceo5s Sr. •; �`����°`^ � COMPENSATION INSURANCE - � � � - � owNER . �`��;,.,`. e ��"(This section,rteed'not be�completad ifYhe work inva�ved by�,��' - � ��oweR � � � - � ' , . �� z-: ��'"P+�sihe permit is for o�e hundred dollars{Si00)or less:) tAVATORY - �MAiL . �.�� t , :' � �: �' �"'+� �;-�� �.,�� - : - � � . - k,'�ix� .� . �_' �� -ADDRE55 / z?�:�. �`,'�c 1 ceriify that.in t1ie performa�ce bf ihe�work for wFich th�s � � "��' ". ��` parmit is issued,i shall not amploy any person in any manner� I SINK C�7Y � �� �TEL NO. ���a �yr���,y�.;-, � so as'do 6ecome�su6ieatdo Ihe-Workers'Compensation Laws ;,DISHWASHER f� - $ +.���'� .�'� ���'. _ - ' :; � � �=�� - - �`:I� R ;� �o� ., �'` .—�. CONTBACTO � � � . ,��^���,DaYe_ Applicanf x�''9,� CLOTHES WASHER -- .w �r �' �� T[CE'+�TL1::APP��i`AN7�.1.��'.�=.�_k t.���f-ytif.i+t�;���_ .... .. � . . � ADDRE55 _._�+�D �.� ;:£��.,�..� : � �y§ �°E>em fron, ou�shouid become sub'ecf to�iNe Workers �'� � SWIMMING-POOLREtEPTOR - � - � . . �Q�����-�� e ,,,,'� - P Y { a.: ,GTY�.. . . � � .TE1.N6. � � . -npensopon provisiona af the Cabor Code you must forih ,�,�; � � � - /� � -' � tl : _ . SPRINKLER SYSTEM i J !/ s t?,":. :,�,:, e me�revAked�.:-wch provisions�or this permkf�x�all�e.� £���;,WAT�HEAT@R� �"�'.' ,'iI� �.14 ..^-".�IICENSE NO: !��/� CLASS ��'� "��.��*J' � y z .�..�.m.f�F�..Ct1`�22,.L.�iS.RA.CT.1�&S^F.i!Fti�r1.-LC�G'e:..,.�,„. s � _ _ �_.�,.� _ _.. ___' ' .6`D TR F'��. - .-&R3L'z.55�d1.6�X�..,..�. . , � :--""�'.-- : b CL+ . � _ — _ � _ �� . _ . � �_ '�. _.�._�.�___. .�_ . _ _ ""'�' 7 here6yaff�rm that}am licensed und r provisions ofCMapter 4 z�'- ���-- G,4S5v5iEtu� SpUTlETS ?' '. i -- z �'S z' `� ���` ��`'commendp with SecfiQn 70�0 of D sion 3 of ihe-9usiness�'' � � �� � �'��"''"�_ ( 9 ) OUTIEfSpVFR �-�.�,. ��. � anr.�ProfesseonsCode ant{.m"t'sc ns��5.ert-fyI(fo�ceqrid-e#fect �: sPtRSYS1EM - .,����_.,__ -:INAl.� a. v �, �����-y - � ` -e�`�.�� VAtiDATiOi� h �'.. ��Licensa Number����� L7c�Class ��� �-��= .�i�'�^✓ �� � ��y ` dATE . L���a . :- . � -� �- ` � . $�+�`� , < �r,' ,�., -P�, °�� ; . � SY AL �"N ` 4f,��'� '. ���-�.Contractor ' -Dac'��: ..; . . ���,�` -. �:���g^:. �_.3` �..l:.o'R'ExemPY,`:un�e[,Sec.-- ,...�._.. ...... . . .. .. . . �. � � .. .:� � .;bS :. _ �_ � .,,. '� .,a,..., a fi^.�,3' �y'�,,, AiL..., v��� �"S���P C�fo1�#lus reason -_ �'�s` :..� � ���2�. � ��;�t��,� f �'��.`�g�r�,`�`�"i��s�' '. � ��+*`���;���;�.�t. �-0��`.. ° ,��- Plan check fee�.__ .. �`��.;.. _.�� �`"3"a��..�-�;�""�'��`"�C��'_c,��'r�1� �,�"� .�.:",; I�`� �. .�. . . "�� _PlUMBfNr'i=PERMT'f`(SSUtNG.�EE$`" ,:�£y��� '-� ��+ u��P���"�'� �a-.a.��a aa��t�.��' --. $ -.a $[g[13SJF2� . . �.' _. �.�.-._ : , .. j :x� � i"+'t � x*i'r' 3� '} .� g �, �.�. s .< :� � �� ... : . �::rCa7AtFEE:� . }�:. �s �: -�^ a "a*�t� �#�' �^, r� ��` ��3Y`� -L'��t �. ¢`� z�'3 ���.-,�a.=.�� -r ,�.�a,,� �a.�,> . -zd� F� � -^:- a"����� ��'�.aP�s� 7� �e ;, � +asa`.er�'�r Arw�fi�,�� a��sw�.�, a ,�`�ea�w.� ,�i'r-t m- Plan check appiicant �� ��:� tt����'m�-n a�� � . xre �A� ; �� �����."�"'-+�;�A";SiNGtE;PAMILY=4�a.'�.,���'*-�� «g ��, . -:zy t� s�. -�:� �.� s z �: ,� � �, we-. �.�,. .. . _ . _ . . �"" ,x,h kf�t_ct3i -a� `�- c�,. .:�� HONzC;OWNER 6UILDEI�:pFCLARAT#Ot+F "' �.n' Name � -�s.r r�,� z�=� -� 7`'� '"`�:�-ml.�refe�ij:affirm thati am exempt from�the:eonh3cter s ticense��.,�� ��� �`-.. '� �� . ';.� : x� �- ;�,�? '�- K§"s � �.. - for��he fallowin reason Sechon 7031.5,8us�ness an � �+dd es�:;�„�„�;.,,,�,;,�,,,,,,�,u,,,,�,�,�,,�,.,�„,,;,;�y���,,.w;;`�„ ,�„�;;;,�_ '�� ,� ,,,, ,�,,, �- �'� � 9 { `�`ar i .,.'��r-'�r' s' x�,,�,'�"�."'�,x,,��,���..��'�Z�,�'��� . �esstons Code}�-� ,� -' Gt � Tel.Na. '`" '� i- �v �'� `�� d. �`. Y '�.,u ;� ,���nr�,�P�i.r k�c�r''�t°.3"�� �-`;,ar�'� ; y � { t k�'��'�Lt��ia?as�owne'ofrthe�praperty'"ewvl��do'ths�workant�ihs'�'��t-. � - �; s �'�� ,�, �^�,.���'��"���"�'-��`��f?.� f strud�re is.:noi imended ormoffered'foi�sale'SecY[o � `�'"���" � �'" ^+� 3� � .� � �y,<$�t� ��,7044,Bus�ness and�Pro#essions Codej � �(. � �'- --�z��'� ���a '���2�"�..���.��;���.������� 6 •'. 4 _ � �*. � �� . �� �� -- CONSTRUCTiON IENDiNG AGENCY r. �- : � �. �` ,�n� �� ��, , ' � � „r � �.�,u,.' .,�,ss " I here4�y affi,m Ihot-#here:as-�=con�t�itti�n le�ding�cx+ency{a , ��� ihe�performance�of the work for which t��is permii is iss�ed�°' �',,,'":'�'�.��;},�' �F",� ��-., � .��- t . �� � � "� �, ' � �' " �`�`;� ,� (s�c.3ov�,c� c)'_ �� �" ��� � �� e�� `��z� „�� �� $�, � �- � �`� � �. M1 ` �` ' .� � . , � , �"��s >p-a�� %r � f� � � �`,''_k+ . -Lender'�s Name � .r. r k �r '�, i a h a . 3 �� -� . `f ,# .�. ��+�'= t . . � � '�S�'w f�..rv„t y 1 1 ' t� k -�,� . �`�` �; t � "� Lender's Addreu �- � {�'���° � ` �' i s.' : h'�r � #��g s ,��., .. -�M d --.�. ,`��;1 certify�thai i hov.e read tFiis ap{ilicqtion and state�.that the ���������"�` ��. � �x� : � �„ hYr..�t �i� ���.. �" �.�. { �:, .nhove informdilon ts corred.-�agree fo camp�y with;alPCoonty�- "+:� `���� �4`�� � � � '� � M �' �'.+.� ,'��"� t � � �"��ordinances and Stote laws-regulating_Plumbmg,and hereby er ��,�r:� Ij sF�r� � y f a � y�� ,�� r '�� �;�, �' '?�,'," �-aulKorize represe�iotrves�of-ihis Counfy ta entar upan the'� aH' �'�w;� '' � �;� �i 'y' ���`� �" �� =ab e- ntaon � �o ert for�m ection� or oses. - 2''� � : �"•`°` . � .,y'�� ' e. . ��- P P Y P P p � ��z"SEE�REVERSb>POf�EXPIANATCIRY IANGUAGE ��e �� �� � �/ ��:�� � ���'' a t � � � �� � �� ��k � �f� � � � r� ,�y„y_ � _ . � � � .� d.E �� � � �i � �� ,,,� Signa ure af� milfee Da1e ��, p""�. , . .. �.� � s � :. w� 4� y'� .� _ �,��.� _.,�t,r��,,a Si � . . a�.��.w ':kr�`r " �5. sxts��`r.* �,`���,'.,,-�{r' "� " �� ��� z �s� c o � � O z �r- � s� , y v, -a cn rn c o ( � m� �Im w � ��.� a A . . 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