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HomeMy WebLinkAbout1236A (6) _ WORKk:RS'COMP�NSA'CION DECLARATION ]6A66]A Q�p' ��^�T 0 n N F�R P�t ��p�N G �9 G R 1�1' 1 ,�g . ` �;y a7firm ins: : :.a�.c a cc;:�:icaic oi conset¢ iu seii "s:�(raoj ' " , _ ' �] r "'s iI � rnsure,or a cert�ticate of Workers'Compensflfion lnsurance,or ��i � �1 ; a certieiea copy thereof(sec ssoo,:,a6.[.) COUNTY OF LQS ANGELES BUI IDtNG AN D S A F E T Y ' Po;icy N6!�C Q�mpany�EIL.4���� � . i '� ❑ CaHified copy is hereby(urnis2�ed. � �M - FOR APPLICANT TO FIIL{N(PR�NT OR TYPE) 6UILDING // {^.��z � � Cerlified co NUMBER F�XTUi7E OR ITEM e FEE 'QDDRESS���� � �((L>j�-� !/n� _- � � py is ftled with r e county bui in 'nspe n /� 7 p����� ✓ � �WATER CLOSET LOCALITV �,f,,,t�/ .. p�!1 �f;�'�� � Date Applicant IVEAREST �rV i a l�la J�� i 'BATH TUe � CHOSS ST. __ -� �,� �' CF:RTIFICATE OF EXbb7PT[O;V PROM WO12K's iS' �� - -__ __. j CUMYY.NSA'I�IONINSURANCE SHOweR OWNER . ._ -. LAVATORY ! MAIL �-. (This section nr.ed not be eompleted if the woik involved 1 i aooRess '���� by tne permii is ioi one hundred doiiars t$i�6} or iexs.j 'stNK I � � CITV TEL NO. 6� - r i certify that(n the performance of the work for wfi�ich this �' 61SHWASHER � � � � � � �� CONTRACTOF� � � - perm�t�s is5ued,I�hall not emp(oy any person m any manner „ .._.__ _.._..._- � ' / -•� � So as to beCome Subject to the Worker�'(:ompen5atlon LaWs. ' CI.OTHES WASHER � � � t� ' � .. ADDRESSI�-�j J r6 d v��. - y- ... Date Applica�t ' . --_-_ ___r.L�v � � -SV�IMMiNG PCQL RECEPTOR� NOTICE TO AYYL(CAN'i' [f,a}�er mxking thls Certificate of CITY 1 ,J��l�`f��✓� TEL.NO�_' .,-� 5.2�- Ezemption, you should become subject to the Workers' LAWNSPRINKLERSYSTEM �<='� — � � I STATE �''y LIC. s- ,,_„ �'� � � Compensati�n nrcvlsions o"fhe 1.ahor Code,you must forth- � LI-CENSE NO.r,[L _�_ CLASS�- 6_..-"� � , . �vith cnmply with such provisions or this permit shall be WAYt�HEATER I ` deemedrevoke@.� — ..� _ ._.._----_�._._.. �----" � �, ` OISTRICT NO. PROCESSE�BY y .GASSYSTEM �UTLETS � ' �J �f �- �/ a LICENSEDCOATTRACTORSDECLARATION �pUTLETSOVER � C_-�"" ���CI-L '✓' I herebe afflrni iiiat I a�n iicensed under pxovisione of Chapter �6 PEFt SYSFEM � �� -���- �- ; 9 (enmmencing with Sectiu��7�00)of nivision 3 of thz Busi- � FiNAL VALIDATIOR - � ness 2nd Professions Cude,and my license is ir,full force and DATE _ eft'ecf. License N�mheP�1 �p Lic.�Class +`--��� �� . - � gy - � � Confractoe��1���� �J Date �'-!�'�r�� _ - � _ � ❑ ��. - i am ezempt from the I�censing iequ¢emenis as i arn a Plan check fee licensed m�ClSifeC4 oi n t¢g:s4eted pmfessional enginer.r pLUMBlNG PER[NiT lSSUING FEE$ � --� -� . � i � aciing in mV pro�essional capac�ty(Sectinn 7051, Bus- _ � � ine,cs and Professiuri5 C:ndz). TOTAL FEE �� ��j - � Lic.�r Reg.No. Datc .� Plan check applicant - t ' _.- t ti.A (. _ �, .�IflME Ot4'NER-BU;LDER DECLARATIOV � �� Name � , - � � ;: Address t s ��{�` � 1 hereby affam that I am ezempt from t}iz Contractor's � _ . License Caw for the foltowing reasan(Secti�n 7035.5, Busi� City Tel.No. :t �� � j 6,,^ . ' and Yrofessloi�s Code): 1 �.c . . .. `,'r . I,as owner of the pcoperty,am exdusivety contracting �`e "� with licensed contractors ¢o eonsttt}ct the project � , (Sect'sun 7044,Business and Profession�Co�3e). � �,��.'Q� i �'�.`i � CONS�1'RUC'PION LF:NUINf AGENCY � ,,, , - - i here6y affirm ihat there is a construction lending agency - � _ � for the performance of tiie work for which this permit is - � - . . issned(Sec.3097,Civ.C.). � � � . . a I,endec's Name ' e Lender'x Address__,_�___ . � � . � - $ I certify that I h�ve read this applimtion and.state that the - �� � nbove information i.s eorrect.I agree to.comply with all Cnunty Sgg 2EVERSE FOR EXPLANATORY LANGiJAGF, - � ordinances and Stnte lawa regulating Pluin�ing, and hereby � - � . - ., i author'ae representatives uf ttiis County to enter upon the � . . auove �a��tioned pr p�[ for' sl�ection purposes. � � � � ��� � � ��� � � � Signahae of Permittee ate - - �- - � . � �z ' � � c c� �'�s c�_�c�. � �, ,Anv � � r- cDi��C `.� n i� O Z _ : „ � . _ � _ �� ... o . , n,i � � m ;� p m -o = � �. . z =o -o . � D77 ' n � 'G7 m 2Iz v .tn � —� r I r � . � �.� �I -rii71, .. � I Ip '.._,s p�i �I -x1!n' s��W I A � C;D W '�i� D ., I-n �, � ,. z O i � � . 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