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HomeMy WebLinkAbout1235A r �bORKERS CObSPENSATION DECI ARATION ��awss�w p{ `/� p�^ p� { 9 { A' p,/r �s.y� � � I heeeby-aPf m thnt I`have,a e.ert�ll ate of consent to self -ce e��(z-aol ��r�L.&S.oPS- ! �Ol�l.��oR�`__.A-���-'_!Y�P�^�:YS�eT _- {' , '. :_.in .-a--� r___.:.::�.wwe.�.�-...,r p.;e�itronYrsurnnce,or ' - . ��- . �.� �� �� f,� � a c rt�t�ed copy thereof(Sec.3800,Lab C�.) � � ��� � �A 3-�� n� COUNTY OF lOS ANGELES Bt1tGDkNG AND.SAFETY � Policy N�n'c�9���Com?pvny Ei9 �/�f( � .. . . . . .. � . . '� ❑ Certified copy is hcreUy furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) gU1LDING /� / � � �/� � � A�DRESS ,�Z�-,s�J!'� � �J /OL�� � ��� � Certi4ied copy is filed with th counfy buiid' ' spe.[� NUM6ER FIXTURE Oii ITEM • FEE ' ' �.. ��L�v. ___.—_ __ .— LOCALITV ! .1 �tJ �y ' ... ��-e � ,�t� _ 'WATER CLOSET - � ��d.�fJL_HI-fJ.l Y p �.> �:�. � Data ApplicaRt � ..._._._ , __,._ _ NEAREST - � ` BATHTUR CROSSST. _ ._ ___ -_'.� - CERTFFSCATH OC LXE?dPT[ON FROM WORKERS' � t �OVfPF:NSATIO-.'�'[NSL`RANCE SHOWER OWNEft - � �� . � _—__ _.._—_ .. MAIL - ,. LAV/�TORY b (This section need not be comgleCed if ttie work involved aooRess k� _��,_ � by U�e perntit is fox one hundzed ctollxrs (51QQ)or less.) SINK CITY TEL.NO. � � I certifY ihst in the pe*Pormtsoce of the w�ork for whirh this DISHWASHER �-- � � . peimit is issued,I shAll no[empluy any person in any mannei . _.. ___ . I CONTRACTOR ry., t � + �r.� � � � ,, so as Yo become sub}ect to the Workees'Com➢eneation Laws. � �CLOTHES WASHFR I ADDRESS [ -'. ` ` - � C�T 3 Date Appticant - � �'' '' �" ; ��SWIMMING POOL RECEPTOR � „�.} . � ^i(�TIC£TO APPLIC4�T f a fer making thic i;�rSiCuate nf ���----7--- �---� ciTY �_- if. -� �-'��� TEL.NO� ._��Y` �;t� �F;� s P wlth such rovisions or this V-� LAWNSPRINKLCRSYST—EM—�f— STATE� v LIC. fn � �. k� � p p permzt sha11 be _ _�—��� ` �� Lxem tio�, you should become suhjec' to the Warkcrs -�����EATER ! LlCENSE NO 3 �+- CLASS �"-�� � ,� � Compensation pxovisions of the T.ahor f,ode,you mUst for8� w�th com iy ' _ deemed revaked ' ,. I �Z- _ , IGASST`STEM OUTLETS ,... DISTFICTNO. . PfiOCESSFDBY �'y �..� .-.f,itF_?dSF:�33�i:{1iVTRACTt7R:S-�DECLAFtA1'ION�-..-. . p TLETS OVER j I �c.'./"��� I� �� ^`� ' � 1 he eoy affirm that I am licensed unde provisions of Chap[er ,.� 5 PER SYSTEM i ! --�"— -�-�� 9{�ommencu�g w�th SecNon 700o)r,f pieis�on 3 of khe Busi- t F�NA� �A�j�AT��� ''a�� � ness and Professiors Code,and my Sicense is in full foree and DATE � effect. _ s `--�--fi—� i y� 1 �p FifGAL� � Licensa NumberF�LG.L� Lic.Class `����! ; gV C}' ( / J Confxac2or�� Date-6�f ( ��! � — � � � i am exernpi &om�t e iicenxing requ'vements as I am x ��p�8�ClleCk f20 �_ licensed .�rch�tect ui a regtstered professionul engineet � - �LUM6ING PERMIT,ISSUIfVG FEE$ �- -�- � -- - -- � a�:. .acting.in*�y.p�of,ssipnnl espacitX(�ecti�r-7643-,-$us- —(�—` ��-' 1' r " , me.^.s and Profes;ions Code). � i t'T - G �'.� �` �. TOTAL FEE �� �'� ,-.� � ��; , . � �.—'_..__._ '__ .- . . ' l,;c,or Reg.N�._ Date �pfan check applicant . ` ;'sg s,B . = n � HOML;CJVdNLR-BiIILDER B�;�LARATIO^i -�.Name - � � � ` x s rv � I hereby affirm that I am exempt from [he Contractor's � Adtlress � �� ' License I.aw Por the following reason (SecEion_7031.5,Husi- ' City TeL Na. - ;^n 1v�-n� � nes.v and Profrssia�s Code): . _ � .- - �` � -� 2,as owner nC the property,am exclus:velS��ntracting � - � with licensed contractors to cnnstruct tha project � . - �� � - (ScMion 7044,Business and Yrofessions Codc). , - . !. C.ONSTRliCTION LENDING AGfiNCY . - ,._ � ,.�.;.,:.. 2 �„ ___. �- ' i herrfly affitm thaf there is :f cQnsE{uction.le��ing agettcy . - _ r. r �"�foc tlie�perYormance af the�aork for which thls pennit is _ ��. . _ _ �,, � issued(Sec.3097,Civ.�C.). Lender's Name Lender's Address I certify that I liave read this applicatiou and state that the � - - �� - abo�re informahon is cerrect.I agree to comply N�ith all Coun+y ' ^ SEE REVERSF.FOREXPL.ANATORY T,ANGUAGE ''orQina�ces und Siate Inws reguleting Plumbing, nnd hcrefiy � � - ?- �(' auihon e r;�resentatives uf this Cuunty to enter upon the 3_ebove-. entitined.propaF[y r insp y� on purposes. ' � - � � � / . _ �r �� g _. . . �_ _ �t� ,j v. ._ . . . .. .. . �.. Y _. �- S� atuce of Permitte � Date � -- � � � � _ ..,.. . .. _ _. .. .. . - . . . . . :� _;. � �._ ... .:_ . . . ,.,_. . . � -: :..:. ::. .. ._. ... �.,. ` .,'_ __, --;- ':= ___ x+. ��a����t,n1�,� _ i-t��Y�vG c�-k ,�p U''`'�-`�n�Px�;.,. �2. i Z'' 'j- ,,v� 1� �z M G��°'`S, �F�"a, =t� �? �.n,=a < �[�nd '. p '<'n' Z }'-tIZ.'Z r � p>t . ,..._�-l�. � 1 tP � fs� -i,,�'G y G. , T�-i � - ,�'�' -t` � ?�'u' ➢r � 2 �- e, �,roD�'�, O ��� �. 2������� � � � � � , � ���r � �� � � .- � , . 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