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HomeMy WebLinkAbout1229A - .�. WORKERS`COMPENSATtONRECLARATIQN ' . - , - .:I�'1�i`L��l'!7�����������„�/y'���V i��1UM��-F St� �. 1 hereby offvm ehat 1 have a cert�ficofe of cvnsent ta seif ��q�ylp - � . - � insure�or a certificot�Q�kYotkers'Cew{�nsotinnlnsuransa,,.----CE&i��(REY.tn/@tj - ____ _!- ..-�.c �,`._ :. _ _ - � .:� or p�tert�fieef copy thereof{Se�3800 tph,G.� -.--. , - :< � � CQltNi1!OFL4S ANGEIES .. ,�t�ILQIH�A��AfE�3C a�ot��yr�. _ _ �. FI�E�t _��S +: ; - -. _- -- - — �- ertified.copy is herebyfamished:� -- _..._._ _,,..:_ ' ,� .: .. � _,� .--,- ��`'�� - - - - *."� ..Ceet�fiedcnpyFsf�l�dv.r�tht� . _5���( .:. -_ _ .: _:._ -��pR.-Aff'[if`4tfTT6ft[tiN{PRltvt-.bRzxvE;�.-'-_.'�_"-'.:9UlttltNG" �.' __ , _ _ ' �ntrRi f��nsPac _ _ ._- -- -�f3�S5�+�.���'t�£��}L. ��a�/�.� .-� _ ' -iion i)eParfrtten� � .. .-.- - � NUMBER �.fIXTURE OR RE7h -� � . . - . � .. FEE -tOCAi7TY._.fJ / -: ___ � - _ _ ___ _ _ _ _ '��� ..���� .� ... .-.. WATER{L65Ei=. -.:. . ._. .._ _ _ � �r.. � r � _ i.�. Dpi __ ,_._....A�i4oaf ._. ..... . . -. - t�EAB€52___ �� - .:�.. .-.:: �: _�ERFIfICATE QEFUF+uicr�nni co�ee ��_ --- -.- �" " ,.-- . - -- --- -- ----- -- --- ----- ... . ' '� ..-. _.��_ "�" � .::._- .._.-'_. ,""." �,�...:.�$A�F1-Tk3$,_ „_ _'_ '_'�_ _-_'_"'__G{i43S.FSF..,,_ .__ , . __ ff>1kYPfN$AT1ON-�FISURANCE _. _-.- . . :.:. (Thh-toefi4s.awtlttW6eeeee�pFpf4d�iftl�work•irtvalxsd�6Y .. SHOWfR � � OWM14ER - Y� .. _ . . . t f�FQ permit is-#e�on�(wmiretl dpl(prs('jl�}or Eest.J - (FiYA7QRY - - . - . . . ADDRESS ��`� � �/� /�' 1 cert"rfy thot-in-Me periorrtiance of-fF�e svo�k-ia�-which this.�.. -.-permN.esissved.-1-shatfnai9�ipfoY�iiy`PersonFrrartymarirrer- Z/- �� � .. . . . .. . .- . .._ a� CETY - .. yl��.-. -TEL.NO. � . � .. so os to�became subject to the Wwkers'Compensotion Laws. - . . . . . v - � . .� .... .E- . . . DfSHWASHER . � � -- � . , �ate� � � 3 n - CQNTRALi4R ._ ppl,cQFli A 1l1 L�EI'l� � 0.0THE5 WASHFR "" t�,� � . h �CE 7¢�ppLICAFfT_tf, pffer moking ihis CertifEcPfe ot �� ' -�. --+4�DR€SS - -i / CE { ` phon yo��'shouk� beEome suhjet# W tha:V�lorksrs'. -�. -- SwiMNflNGPOCk itEf�,fFQR. � --., . :. . a . ... . . .-.- �. .:�- .. . � Ca�rtpensabwn psavrsrons of tite ta6or-Code,You�mnt forth- � E�TY . . �.�.� - - ; . - with comp[y wifh wcfi prov#sions-or this.permR shalt ba ���SPRfNKIERSYSTEM � STATE � � � � deerrted�revoked. �_ . . . ._.. UC- - �., wwreQ r�r.iER ttce��vo. p�,u �' L{CENSEO CONTRACTORS DECtARkTk6N � . . .. . . - ����Q. ��� f hereby affirm.tl�!!wn 4icensec#�nder pror�srora ot Chvpfer 4 �� � GA55YSTEM �-- fri1RRS�.. „r. � . t�/y_-�. . � . . . (commencing with$ecfion 7QW}af-6ivision 3 04 the Business (�}ilET54VER . 4{~ ���� . � .. .. �. _� arxf Frafess�ons Code,and my luense is irr€�1}force mid effed.--- 5 PER SYSi€M ..;. .: ftNAl - .� . .`� - �,.. . t�cense Number� 1 � �t� - _ _ _ DRT€ YA ATIQ�1 ^-_ a' . �Cie.Ctass� .�{^.. �f-\_.��.'��"^"-.�_ .. -�. . - U. .. Gonirac�a. � ���' �-i...f Dm�r--�f-Z� � _ � _ .� � .. . . . � �. ' . � �NRL �.:..". � _ .. - _.. . Q' Q : - _ � I am exempt under Sec,... .. .. . . . .. . . . _ . � . _ . . - . . . . . . � ; . . � 8.&P.t.for this-re¢son � . . - . � i tIf , Plgn check fee , � � � - Date: - . . . ... - . . . � � . ' � PEFIMB[NG P€RhAtT iS5Ut1�tG EE€$� - -_ . � � .Sfgnatwe- . - � . . . . . - � �.. � . . .:. . . . . TQTAL�_. . . � _. � . ' . _ - � - . . - � � - Ptan check appfimnt -� 1cc4A � - StNGLE fAMttY � - H6ME_OWN€R BLt1.�4ERDECIARAT14t1 _ Name . , - �� by aHirm that i um exempt from the CoFlhactor y Licerrae � .. -• ; --_� -. .._ ..- _.. -- -- -- -- _" :.� . �� n m s� : S � ,-. ,�.. , _. .,_ ,�,� . l�. ror tE�s foftowing reasan��(Section"�703i.5,BuSir+esr artd -� Addres�-- - - -�� -� - - � -( • j (��v(} � . - . � � Profess7ons Codej: . � - - � City - -� � Tet No. � . . � . . ❑. -I,as owrter of the property,wilt do ihe work nnd the - .. - - . .. . . � .. . - � . � - � •° 1 ���.t�'.Q�.. . .structure is not infended w offered for sule(Section � -- � -_ _ � �-� -- . . ����,�a 9`�� . � ' � 7044,Busi�eis n�d Professioas Code).- � - � � � . . . - � . . .. - -� CONSTRUCTtON LENQING AGENCY � - _. - - . . - � � - � - � - - � - F hereby oNirm fhcrf there is a conshocti6n lending agency for � � . � � � - � - . - - � - � - � ----� . � - -.�- the performance of rhe work for which this permit is issued � .. - - �-� � - - � - . . (Sec.3697.Civ.C.). � . . � � � - - � � - � __ ... - . _ � � � � � - � Lender's Pbme . .. . . . - . . - . � . - . � � - . � - t � � . _ - . . .. � -. . . . . . . _ . _ ._ . . . . . ! lender_'s Address � � � � - . -.. . . .- � . . - � . . - � � - 1 certify that f have reod this application and stnte that the -. � .. - - . � - . � . . - . . � above information is cwrect,t agree to comply wNh a41 Coonry - . - - � - - . . -� � . . ardinances ond Srote(ows regulatfng Piombing,and hereby. - . - . - - � - � . - - aafbprize-�epresentmtives af ih7s County fo entar.upon the � � --� � � - �- � � � � � � � - -� . a6ove-ment�pert for inspection purpases. � : . - . �. . .� . . - -- . - � .. . . . -. . ? SY�� SEE REVERSE FOR EXPtANqTORY tAFIGUAGE i f . - Si atnre of Permiitee. . �Date . . . . . - � ' � .. . . . . . -. . . .. .. � w � . , � m-� += o o�� � u C � C . N C -� O "D_ Q N �� a �. .. . � ,� O G,.Q � � � ;�m� . � . �n �riv N � ns 3�f' � m.�c p , m p� �mEc� Y `O' '= O N � N G O.. 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