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HomeMy WebLinkAbout0779A (4) � WORKERS'COMPENSATIONDECLARATION /�pD� ��'ATI/�wl �^� �11�!9.Q,we/� e�r^:�IT „��._:r�n,� �, a-o: : �.�,,,�,:�v�v o v6a � LkJiViu�t�Id"J ��RIv 11 C� �:�--:__ I he�cby,,o�,mllhui i fiovet u certinm�e of consent to seii in- �,����p ' . sure,or n rorti(imtc of Workers'Com�ensotion Insuranca,orn CF 8n IRtV.e%861 � � = rer'tified copy fhereoi iSet.3II00,Lob.C.; �- � Policy No.7�Jd.C9�5Q4�(d9lFl�nyDJB7'IONWTDF.___ COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS z � Certified copy is hereby furnished. •D T• :42578 y �- _ FON APPLICl�NT TC)F_Li:N iPR�Ni UR TYPF; 8��i���N�' Cer;ified copy is ided with ihe m�nry building�nspedlan F��k`S:�Q$_ S��TH LEYLI�ND DR 'j depar�men+. NUM6ER FIXT�JRE UI2 Il'eM � ��C ---` , -- L7('.A�,,I!Y � wnrF�c:�osEr�roi�eri _ - F--��L�I(�NB-�I�- --- ) cERiiriCATEOFExpM,an+.NF.W PT.t1NiBTN(' -_ .._.__� 6 �$2+___ ��rk� r � Date9-1-8R A hc * _ ... -... ,_ �,en;sVsi o?ION FROM WURKERS' BATh�I?:1B I �_. CRA�T��{j� _._.___ n� COMPENSATION INSURANCE� �� { n"�NER s!�ow�R � i I _��,I��Ell- (This section need not be comple1ed�f the work involved by ---- -- � ---��� �--5-�-� t v,.�il. � fhe permif is for one hundred dollars(S1Q0)or less.) IA\�A?OkY � I �AJDRFSi ��S 1 ATRj�T 7 I certify thai in�lie per(ormarce of tF.o evork for wh ch this perv - -- - --� ---� � I P Y Y F Pr:n Y �— D S 1WASNEI2.'_'_—_� ��TRAi r��OSTA MESA ���. NU � mrt is issued,I shqll na�E�m Ic on �erson m an manner sn as!o become sob'ect to the Workers'Com sot on Laws. � �� y � i«�..__ qpon�a� — I-��-oi ir �>sr,ra T- l, H NLW Pr rrnau7nr� �kAC_ � _- � •�oeess T � �Ce ro n�Pi ic'a!vr i+ e+iP� .k�,g h�s c�.r��o�e of[x r i -i 2141-S,r ni rnnnrT__DA�V� r SWi.AMIfvC P('OL kE EP7Uu �--- � �ion,yau should bec ,sub�z i� the Workers'Compen- _ .� _. .� r,._..�-���,iv _ - i N:, _ so.on prov s ons of ihe�nbnr C<da yo i0s1 forrFwdh<�oinp- I qN�So41NK.ER bVS'EM -� � � A'�IAAFTM ly wf!h s�cF provisions or ihrs pe n sh li i�e.deemed re�ok �_ _ _ �-�i`n, . � ed. , I W!�ER !tAlcK �. _� \�E ti� � .A. - a �!CtNSEOCONTRAC10R5 ;iC 4RATI.^,N �—� --� - -- -- ----f- � - JIbtBIC�NO RUC�SSECev J I hereby affirm iha�I om licensed under provisipns ot Chapter +�___.L� fI�GAS SYSTLM � p�i�TS i � `•+''� d 9(comnu•ncirg wrth Sr.ctioc 70C^';of Div�vo,�3 of 7he B�s��,ness " �OL�r,____—_ .._. ._—T- , _. _- _ F v�_ _— I � I i a OVER E and Prcfessions Code,and my license i�in f�li forcc and ef- �.. _ ��FER SYSTG.n ___I ; � FlNAI ;/� � ?- ; �e�i. oarE 'Y/.✓-.(�/,�`� � ALIDA710N 0. � license Number/�.2,(1 nQ Lic Closs ('-�h - - � I - -'- � � � r ) i _ ._...... ._ __. ._ � , CL I PiNA �! Comraci�� NE.W PLUMBING Dore�1-�$_ -i- �Y ''.�su'xt-�"' C? -1----- -- -- M- � _. .. . __.. ._�_+_._' 1 1 �, I am ex�mp�under Sec. � 'u,"� �__.— j, .--. _- ---�--- , es, a aP.�.ror ra�s r�aso� f�lan check fee I � . � �'.'`_ ' w � ---_ -- .--Daie� --�=--pLUMBING PERMIT ISSUING FFF S� � . `�,,. � � � Signalure _..__ . __ --- ---- ' ,, : „ i --_ -- TOTALfEF , , .. { SINGLE I-AMILY � ..-... � �$ i " � �,r:.i. �., � HOMF OWNER�BUIIDER�FCLARATION P�an check app!icont _ _- J I hcrehy offirrn!hnt I om eaempi from the Controctor's Lir.ense Nome � � { I for fho followinq r¢Uson �Secr.on 7031.5, B,isiness and � --- -- - ---� - f1 :ssions Code!: Address �s � � �i ❑ � . - � .-._.... _. I, as ownor of the proper!y, w�ll do ihe work and the City Tel No. � structure is'not iniended or offered for sale(Sectinn 7044, -- - Business and Professions CodeL ` CONSTRUCTION LPNOING AGFNCY p � I hereby�ffirm tfial ihere is a construtiwn lendiny agency for � th=prfo^nance of ihe work(or which this pe�mil is issucd , � (Sec.3097,Civ.C.). Lender's Nome # Lender'sAddress __ � I certify that I have read this appllcation and state ihat ihe � above information rs correcL I ogree to comply witn all County ,� ordinonces ond Sfate laws regulahng Plumbing,and hereby � au}horize representatives of thrs County to enter upon the a ve-me �oned property for inspecho i purpos� ; SEE REVERSE FOR EXPLANATORY LANGUAGE � Signature of Permiltee �nta i � �e��:-..-,.�, �,x=��.�=.a Y..f.�s.,��.�3..�'Y y �_ y{ 3 q yz� � Z f i:T:�";�� :.i�.:(�.7 ' 2 1 �:� r � 1y ' j�'�L:- G�t�+C:C7' .�C, CI . 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