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HomeMy WebLinkAbout1233A (6) i WORKERS`CO;�CPENSATION DLCLARATION �eass�w /� �/ p�/'► , I lieceb aftitm that I have s cert�ficate etconse�ittoself eEan(z•eo� /'1������T��� F�� ���idCR�3O0'w- �����o� c��t� `— - ce.-z;ncste o[lJurkers'Compensation Insurance,or � j�3 - a�cedified copy thereof(See.3800,Lab.C.), - 9� ��gPi �?�G �A t�,'�rr�� COUNTY OF LOS A(UGELES BUILDITdG AND SAFETY �. Policy No umpany « - � � � CertifieJ copy is here6y furnished. � � FOR APPLICANT 70 FILL IN(PRINT OR TVPE) BU�1_DINc� � . `—��-- -- AooREss„cC��� � ,�tl{i �rz . .,� �ertified capy is filed with t tt count buil-' 'nspe� ' � � NUMBER � FIXTURE OR 17EM O FEE - A --����� - LOCALITY y .����� �1/l •-7'<� � Pa .,Y�J pp -=i�/'.�.�v WATER CLOSET l-�P All i s -Date 4 licant "� NEqREST i BATN TUg CROSS ST. _ _ � � '- CERT[EICATE OR EXEbSP'CION FROM WORKE S' - -- - �- £ - COh1PFN9�ITIONINfiURANCF. SHOWEFt OWNER � � MAIL � . k (This section need not be comPletEd if the work involved LaVATORv qooREss __ �� , by the pcxmif is [oz one hundied doltars ($100)or lessJ s���K CITV TE�.NO. ,z„J � � j I rertify that m the performance of the work for which[his DISHWASHER �� � �permit is issued,I sl�all not empioy any person in any manner __ ___ CONTRACTOR �� ., �, �Jt.e 1n,S�- Cg . ° su as to become sub�ett tu ihe 14'orkers'Com ensatiun Lau�s. �. T —L� "� � J P CLOTHESWASHER ' ' i Date ApP7icaaS -------� AO�RESS G7 ��. �t„��.. �„ �`.3 '. .__ ._ ._—. ' ` � i �SWIMMING POOL FECEPTOR � ,� �. _ - NOTIC'E T-O Ai NL€C't NT;[f,�Ptei�making Cn�a C'eitfficate of --{— +—� CITY ��.j���X�� TEL.NO. .--�D � ' �.�xcm tian, you choul�3 Uecome sub;ect to the-1V�rkers' LAWN SPRIIVKLEii SYSTEM I, [���„� �-- �'is___ p I STATE LiC. �Compen5s4ion Drovisfons af the Labor Code,you must for[1t A § �with cuntp(�- with such grovisions or Ehis permit shal( be WATER HEqTER i ItCENSE NO.� , CLA55 C_'� � ,� deemzd revoked. � � OIS7RICT NO. PROC E�SSED BY - �GASSYSTEM OUTLETS !i I � `� �. LICLNSED CONT'HAL'TORS DHCLARATION OUTLETS OVER �� ( ����� � � �- 1 he�eby afPlrm that Z am ticensed uo�ler proviaions of Chapker 5 PE R SYSTEM � --- 9� ��_� _.___.. .�.— FINAL � 7 (eomrnen�ing with Section 7000)of D3vision 3 of the Busi- Vq��pA-�-��N ness an�Protessions Code,and my license is in full force an<t OATE . � �effect. � � � . L 1 d�,f, y I INAL -License Nunt6er� � + Lic.Class�.b�� � ,__.._��.: � . �r�� —��'.`1 , � Contractar�� Date ' �,_�__' _i_ �. � I a�n exempt Pr�cm the licen5ing reyuirements as I am x - PI811 ChBCk fe0 �� g�, ticensed archifect nr a registered proFessional engineer p�_�_�pnR!NG PERMITlSSUiNG FEE 5 � �� ° a�tir,g en tr.y piaies���na�capscity (Section 7051,Bus- x � . iness and ffofassions Code). TvTAL�£E Y� � _ . � �.Y r,:t � Lic.or Reg.No.. . _ Uate _ ��Plan check applicant - � �.. - Nsme � � R k a HOME.�)4VN«"f?.BUILlIER L'ECLARATION . .. . ._--__ .__——.— — . i: �' Address . . . � L hereby affion that I am exempC from the Contrnctor's _ _ - �� Lirense Law for the follcwing ceason (Sectinn 70J1.5,Busi- � City Tei.No. � � �� ness and Ycofessions Code): . - . _�� S,as oivner of the prope�ty,am exclusively cuntrecting , ��i�° � L - with liceoced contractors [o cnnstruct the pxoject . - �,^r �'- (Sectiai 7Q44;Business and Yrofessions Code). . - ' - � .� �,. . . _ . �C} 1. ,y r? CONS7"RUCTION LN;uDING AGIiNCY � � � _ �- t hereby affirm fliat the.e is a rons{rucYinn lending agency ; - - . � f'w� the perfurmance of the work for which thi5 permiY is � � - � ��_ issued(Sec.3091,Civ.C.). " ' . �-� Lender'sNamP� � � ' � ;_. . � � . . . . �� Lender's Address_. t -�- � �� _. . �" {: I certify tha!7 have read this apPl�cation and state that the - -. - � � above information is correct.I ag�ee to comply�.vith atl Coun:y 3 SEE REVERSE FOR EXPLANATORY LANGUALUE � � � - � � � ordlnances and State laws �egulating Plumbing, and here6y authoiize representatives op this County Co enter upon Che abn m2ntion d �ty for � ection purVases. f� ��� �� j�' �� -� ignature of Permi[tee Date � - � �__ � _ . _ . ' . �DC ,. � ?�IC � ..�.���n D G z(.� z; � � � _ . `9 cn I z r tn �c' i n cn C p i, �,r-- _._. _ . 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