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HomeMy WebLinkAbout1207A lo WORKERS'COMPENSATfON DEClRR.4?ION . �pp��CA��ON �pq P!tlMBING PERMIT . � � � I�he�eby affirm.thaY 1 hove a certlfi�ate of tonsent to self �bq�7p � - . � insure,or a certificate of Workers'Compensatioo Insutance, CE 617(REV.tOBt} . . - - - � �- _ � - - - or a certified copy thereof(Sec.38aQ,lab.C).� �� - � � � fOUNTY OF LOS ANGELES � . ��Bt11lDINGAND SAFE7Y y� aiCyNo.�1'tt'i,.�'�fc(4F�pany F►IL YiAAN.S - p�p-� c! Iified.copy ia hereby fumished. BttIIDENG / f �y�-� .-.FOR APPLIG4NT TQ f!t!IN(PRkNT QR TYPE) AD6RES5 �j /�� .� I�IJ� C/'1t1J . . ' Certified copy is filed wiih the cou�ry 6uildi�g inspac- � . _. . . . _ NUMBER FIXTUREOR IiEM� � FEE� . t,,y � �. - ��tion departmenE � - � . tOCALITY r . . oo�e"7-�—�5 pPP{i4onf_,,�4 CV X��tU "1.-� war�a cios�t � '� N�er�sT c�tr{F�are oF exen��oM r-�tx�n wo�KeRs Z eam,ue _. cac�s sr. `�! �/y - f'� con,�Er�r�uv5urtr,wce _ sHow� own,�a %l/17 � Rt,►:wexoa n��we b�esmpi�e�u,a��ork iaro�.sd 6r--- ,�n,,u �! - 9 fha pwrmi�ic for oas Fa��r►d rbilurs(Sl�)or uss.t wvaroar � � a�oREss 7 Y � ._ � - I-certify tM�at in the pe�famance of the wwk fa��which this . . . . - . permit is iss[ied,I sFmM not emptay 4ny person in pnymanner SWK .� CIFY � 6 TEI.NO. -�' !7 � to as ta become su6�eU_tqrhe Workers'ComPg��tian{o.,r�._. .--:. Dt5HWA5t1ER� � - - -. � - - � - ____ ..____. - . ��� CONTRACTOR � . . _� Date�`��—5.��nPPliconf,_.s_�f'U��l� ` Cl6THES WASHER . - A60RESS .. . � ��. � tCE FO APPUCARiT:If, after moking thrs GeKtiftcale o# : ��������.� � - _. __. .; .., �� �-, T iption.-�Yov:shauki bec9ms suGt9Ct tp ihe:--VYorkers` :_ .. .... .. "..�.. C:TY � . - . TEL NO.- I �. LL.np�ewlion Provizionsa4Jk�e-taber�tode,Youmrrst iorth- � �..�- LAWNSPRtNKLER5YS7EM .... . . . _ with mmp�y wcth�s�ch pravisions w-this permi� shall �- - .. _ STA7E n tJC deemed revoked.� . . . .� - � � . WAiER HFAT€R . . r` I�CENSE NO. V GAS$ .' . . . � tIC€NSE6 CONFRAGTORS UKEFtRAiION - . � � OISTRiCf t�. - . . PRDCESSED-BY - . . -.� :�t6erehy affirm Ihatl om IKensed-under�ovesimis�CFnptee 9 GYSSYSTFM_ OUz€ETS�- � . �7:.. .. � � . mi - �(€Qmmenciru�witk 5ecteon 7�06)of E?iv�sian 3 0#tF�e Business - OuitFiSOVER - .- .. -- ' --. .. ...> . � a�PraFeuians�Code,and my-license is in fufl fwce and effett - 5 PER SYStEM �- FtryAL - - .. �� \fA AT1�N � .. . , -- �- - --� -. I�AiE�,��'L��` ;g�_ _. ,.. . V.:. A u«�a�.�!�l 6��t �K;c�sS.:�� � _ ae � - _ . � �. ' � FINRt L � . . c�..�.«+�. M �r�w�t�[ ���S'- S`_ g� � v � w �� l am eaempt under Sec :� � s.sP.c.i«rn�s.easo� _ Pfan check fee � z s ��� � . . E3ate: . . �t ..- .� . , . . ; .� .. � - . _ . . .� . . Rli}rVi8kA1G PERM4T ISSUtNGFEF�E -.l� .. � � � � z��Q 7 R � .. � .:. . . Signatore . . . . . . . �. . ' . .. _. � � „. � . . . . tOTALE€E. _ . . . :_. . . _ _ _. _ . . _. .. -y�� s•.�i j � . ! ' . . ��- . . -� �: Pfan check appiicont . .. . . - � . � � � "` - - SINGIE FAM(LY - . _ � � . .. .. � � � .. � • •Fi�J�CI - i � - .. HOME OWtVER-$tJfl.@ER D€CLARA'ltBRt_.. - Name � . . . .: - �, -— - ( �� �,r` �by affimr fhnt C am exempl from tk�a Contracfw's titense.-__ . ... . ...� .. .........._A _�t..::._...x . ...-. _.-__............._�.., .=t.s a.�r��.G>(�'�.. _ . 4��dress - _.. .. . __...... �.�:. ___�,,.. ..�-.� `: :.{ . Ll� .iar tF+a:fa!laswu+g.rsoce�(Setitsri-7tl3'k.5, Bv�iness a�i� ... . ,Pro#essiorts Lode): -----:-- ----- ..-_ � - . Ciry � - . Tel.No. . . . . . .� . :Q'j Q 4'_�� . � �- ❑. f,as vwner of the Property.will do the work.and ihe . � . . . . � . . . . � . � � . . � . . � . -�slrudure is�rwf intended os offered tor sale-�(Sedion . _� � � � - - � - ��. � 7044,Boseness and ProfessiQm Codej. _ , , . . - - . _ � . . . - . _ _ - -- � CANSTRUCi1QN LENDlNG AGENGY �. � . -. _ � �.� � .. ��- - �� . � �. . � . .- � - -- - .. - . .. . -� . -� . - - . . t heteby af#irm that ihara�is a conshuctioo-le�ding agenry�fw � � _ � - �� � � - '- ihe-perfarmoirce of Ihg workfor which th[5 perm�t is issued - . � .. .- � . . . •�. - � � . (Sec 3Q47.Civ_C.i- . . � � . . , . _ .. . . . , . � :� : _ .. . . � . _ . . . . . _ . _ . _ : _ - � . . . . - _ . . -_ . . . � Lendei s Nqme - � - � � �- . � � � � ' ter�r's Address- - . . .� � � .. . . . . . .� ... . . � . � �� I certify thot 1 have read tbis opplicoiion and sra�e thar tRe - � - � - � ��� .-. , - above.informatiow+s cwrecx,I�agree��o compty wiFh c�k6 Courdy . - . � � � � � � ardinances ond Stme laws regulat'rng Plumbin9,and here6y � - � � .. - � - � � � outAarize representafives of ihis Caunly �o enter upon fhe . . - � - - . . �- � �. above- e�tionecf property �nspecrion purposes. SEE REVERSE FpR EXPLANATORY IANGUA __ � ��.i _�� _ - .n— _ i - Sig t of Permittee � Da�e � _ . . . . � � � � - . � � I ; m-6 . . �. � � ;� _ T� 0 O+"O . . � . i,i Z � G p� � O . . . -p G 4-.d �n � t-C' .. � . . . . � O p,p � . p m O� p A . . � d �� d d u p C� � � � a Q.O � �� •S•-r- .: ' . N ,r;�� o "3 o u� o �t a ..�o.o :� � £� � � . . 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