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HomeMy WebLinkAbout1883A (11) __ � WORKERS'COMPENSATIONDECLARATION e��I I�ATIAIU �P>� �I IIMR�IU� DC�AAIT =- a =:��ea�av " �:c : saraa:va:xsv a �'�avas3 � 3 I hereby atiirm ihot I have a certifimte ot consenf fo self 20-0026 DPW 6/87 �' � insure,or�a certifimie of Workers�Compersation Insorance, 76A667A o�a cerpfied„opy the�eof(Sec 3800,�ab.C.) COUNT`�OF LOS ANGELES DEPT,OF PUBUC WORKS � P lity Nn_ r'ompan, . - ' -. - � � � Cerlified copy is hereby fumished. - / € r--� FpR APPLICANT TO FILL IN(PRINT OR TYGE) qODRE55 aya&�7 /,Fr A-�ld�T �l" �' u Ceriified capy is fi(ed with the county building inspec- ------- tion departmeN. NUA48ERT— FIXTURE OR ITEM �r7 FEE . ; � � __—____—__..._ ._�. LOCALITY , �� � � Date Applicant WATER CLOSH NEAREST /} _� JR c� � CERTIPICATE OF EXEA4PTION FROM WORKERS' � BATti iUe � CRO55 ST. da'o Q u 1{ COMPENSATION INSURANCE OWNER �aRK A.. 'PNA/LD �-Thls sectfon need not be com (e4ed if the work involvad 6 SHOweR �� ihe ermft is for ane hundred 9ollars 5700 or less. —�– MAIL ' ( P P ( ) ) Y `�-, iavnroev ��C�,r� � � ao�Ress 4� ��CA��T �r {. 1 wrtify thot in the performante of fhe work for which this- permit is issoed,I sholl not employ any person in any manner � � S��K E (��y CI7Y ��ma 0 � TEL NO. J���?G. � so as to become subject ro rMe lNorkers'Compensation Law ✓a / DISHWASHER � CONTRACTQR �^� t,�r1�.,i..2�,Cf �a ��S � Da�e��'� `�T Applicant `�"�" " �"�"'�� � - CICiHES WASHER ���� r NOTtC TO�T� If, ofter ,al;ir.g h s`'ertificate of. ADDRE55 �',�71�l�.�.� �-� .i���.-� ('�� � Ezempfion, you shpuld become subjeci to tfie Workers"� � SWIMMWG POpL RKEPTOR � � . CITY - � - ` TfL NO. r, "��f � Compensation provisions of the iabor Code,you must forth- I �lf��Y:a;J� �f:`�. ��"";1�/ LAWN SPRINK�ER SYSTEM with wmply with suth provisions of this permil shall be �T_�._.,, , __.____ , I � deemed revoked. � � STAiE uC. WAfFR HEATER LIGENSE NO. CtA55 � LICeiVSED COfJTRf4CTpR5 DECLARRTIOIV - - pISTRICT N6. P[CQCESSfD BY . E hereby aff rm�ihpt i am licensed under provisions of Chapfer 4- GAS SYS7EM OUTLETS \\ � � (camm=ncing-wi!h Secfion 74xD)of Division 3 c?ihe Business. � ��-�-f OunE75 vvER ` � ��'��`'"�'��" and?rofessions Code,and my license is in f�l!forte and effecL `� I f 5 arR SYStEM ��NA �� 1/ �/Y'` VAltUATiOPd ¢�,r . . �C3..�- �`.�t - �- DA�:'}: ;i t �' � f.'�,. � License Number Lic.Closs � �, _ , � F1NAl Conhactor Date �� BY � � - �'. � ❑ �� !om ezempt ur,der Sec. } � �. � B.&P.C.for this reason � � ! , , .. �i� � P� lan check fee �c� � aQte: °�--- � � . - ��. PlUMBWG F'ERMIT ISSUING PEE$ � . Signoturs . � ---- -��= � . ° - TOT�L F�E � � �� ` � .. . � ..Plon check applitant -� SINC'itE FAMILY HOME OWNER-BilIIDER DECtARAT10N Name � !hereby afiirm ihat I om exempt from the Controttor's Lice�se-�- � : - �� Lc�w for the foilowing reoson(Section 7031.5, Business and-�' Address �_a ��-f�; �. �P'Qrof°essions Code): ���, ��}y Tel.No. . . - r�a � � ¢ _ � � G ,IG� I,as owner of ihe property,will do the wak and the.; - � �_ structure is nat irtended or offered for;ale (Section.- � j s, s h � =,;�} - �. 70A4,Bosiness and Professions Code). , _ t. CONSTRUCTtON I.ENDING AG£NCY . ` " ��� �� � ��"_ � 1 hereby afflrm that thera is a canstruction ianding agency for-� i.,� U �t,� - � �he performance of the wark£or which this permit is issued � . ' - (Sec 3097,Civ.C.). Lender's Name � - -� Lender's Address -. � � I ceriify that I have read ihis applicafion and state that the�� � - - . ( above information is wrrect.I agree to comply with afi County(. � -- 1 - orcJinUnces and State laws regulaling Plumbing,and hereby,.� � � � authorize representotives of this County ta enter upon ihe`� � - .. above-mentianed prop ty for inspection purposes. - �� � �� � 5E8 REVERSE FOR EXPI{iNATORY LANGUAGE ���C� �_ Signature of Permittee � ' Date . ,� � � �-R, �,n � F 1 � ..� � . �, � ��,-^'� . [ r � 1 c 2� 3 _'k ,.s � { ; � jv'� " � , € E � � � ��� � � , a a r�" �� � j ! I � � � � � � � `�� `� � . � r l � � ,, � � � ? 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