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HomeMy WebLinkAbout1207A (6) la WORKERS'COMPENSATfON DEClRR.4?ION . �pp��CA��pN �pq P!tlMBING PERMIT . � � � I�he�eby affirm.tha�-1 hove a certifi�ate of tonsent to self �bq�7p � - . � insure,or a certificate of Workers'Compensatioo Insurunce, CE 617(REV.t0i8�} . . - - - � �� _ � - - - or o certified copy thereof(Sec.38aQ,lab.G).� �� - � � fOUNTY OF LOS ANGELES � . ��Bt11lDINGAND SAFE7Y y aF�y t�o.�.{{I ie5/df��pony F►� YiAANS - p`x-� '� Iified.copy is hereby fumished. BttIIDENG / f �y�-� .-.FOR APPLICANT TQ f!t!IN(PRkNT QR TYPE) AD6RES5 �j /�� .� I�IJ� C/'1t1! . ' Certified copy is filed wiih the counry 6uildi�g inspac- � . _. . . . _ NUMBER FIX7URE OR IiEM� � FEE� . .�. . . - ��tion departmenE � - � . tOCALITY .__ . . oo�e"7—.�—�,5- Appli4onf_,,�4 tV X3�JU "L� war�a cios�r � � N�er�sT c�r+F�care oF exeu�vr�oM r-afx�n wo�KeRs Z eam,ue _. cacsss sr. �/ R/� f'� con,�Er�r�uvsurtr,r�ee _ sHow� own,�a fl/17 �� . (This we�xon n�..wt b�esmpiet�if,hk�eeork-inrolrsd.6Y.--- �, . � Mp,k- �j- p � - � }ho pwFmlt it for oas Fw��d�blluro(Sl�)Or_l�ts.� � . LAVATQ&Y � . � ....� A�IXtE55 �Y /. _ . ._:_. . _ . . . � - I-certify that in the pe�formonce of the wwtc fa��which this . . . . - . permit is iuued,I sFmM not emptay any person�in pnymonner SWK � CITY � 6 TEI.NO. -�' !7 � so as ta become su6�eU_tqrhe Workers'ComP�n3a�ian leHrs•-_ _--:. Dt5HWA5HEg: � - . � � � . . - -____ ..____. - . . '��� CONTRACTOR , . . . DMe�`��—S.S� APPiiConf„�`f'UU�I� ` Q6THESWASHER . - ADDRESS .. . � ��. � tCE FO APPUCARiT:1f, after moking thrs GeKtiftcale o# : ���P����.� � - _. __. .; ... .� �-, T iption.-�Yov:shaukf bec9ms suG19Ct tn ihe:--VYor&ers` :_ .. .... .. ".:�.. C:TY � . - . TEL NQ.- I �. LL�np�ewlion Provisionsa4Jk�e-taber�tode,Youmrrst iorth- �� �..�- LAWNSPRtNKLERSYSTEM . � . _ �with comp�y with�s�ch pravisions Or tkis permii sFwll �- - .. _ � STAFE lt tiC dee:ned revoked.� . . . .� - � � . WATER HFATER . �` 1����. v ��$ .�� . . . � UC€NSED CONFRAGTORS UKEftRAiION - . � ��STRiCf t�. . . . PRDCESSED-BY - . . -.� :�t6ereF�yaffirmlha�.lomlKensed�under�ovesim�s�Chnpter9� GYSSYSTFM_ OUi€ETS�- � . a:.. .. . . . �i - �(€Qmmenciru�witk 5ecteon 7W6)of E?iv�sian 3 0#tF�e Business - OuitFiSOVER - .- - .. -- ' --. .. ...> . � and PraFeuians�Code,ond my-licsnse is in fufl fwce and effe€t - 5 PER SYStEM �- FtryAL - - .. �� SfA AT1�N � .. . , -- �- - --� . ..- #)AiE�,�_L��` "°5�._ �. .. . Q-�1 � V �ucense awsit,e.�!�l���t L;e;�CiaseS.:�.��- - �. �. . . . , _ . . . . _ � - S . . . . _. �"� � - _ . � . � � FINRt L \ � .. - coAn«ro. t`'t�t�tA1 t�t� ��7—_S'— S _ g,� ' v � "' �� l am eaempt onder Sec :� � s.sP.c.f«rn�g.�a�o� _ Pfan check fee , � z s ��� � . . � E3a�e: - . . t ..- .� . , . . . ; �.� .-. � . . . � . . RlilrViBkNG PERM4T ISSUtNGFEF�E -.l� .. � � � � z�2 Q 7 R � .. � .:. . . Sigr�ture . . . . . . . �. . ' . .. _. � � . � . . . . tOTAL E€E. � � . . . :_. . . _ _,,_ _. _ .. -. . . . _. . --�'� s•.�i,�j � . ! -, . . ��- . . -� �: Pfan check appiicont . _. . . - � . � . � � . � ._.. sir��e F.cnn«v t ••8 2 5 CI i � - .. tiOME OWtVER-$tIn.BER D€CLARA�tt)R3-._ - Name � . . .: - �, --- - - �� �,r` �by affimr fhnt(am exempt from tk�e Contracfor s titense.-__ . ... . ...- - ...: _�t..::._.... . .:. _.-__.�---._-....._�.., .=t.s a.�r�'G=(Y'c�#," _ . Rc�dresa - . . . ___�,.. .-._ ..... ..� `: :.� . L\� .iar tF+a:fa!lawu+g.rsoce�(Secitsri-7tl3t.5, Bm�iness mxi�� ._ . .-�.. �Pro#essiorts Lode): ----:-- ---- _-_ � - . Ciry � . Tel.No. � - - � . �� . �L1�Q 4"`�Jr - �- ❑. f,as vwner of the Property.will do the work.and ihe . �. . . . : � . . . . � � � � � - � . . � . -�slrudure is�rwf intended os offered tor sale-�(Sedion . _� � � � - - � . ��. � 7044,Buseness and ProfessiQm Codej. _ , , . . - - . _ � . . . - . _ _ - -- � CANSTRUCi1QN LENOlNG AGENGY �. � . -. _ � �.� .. _ ... - �. �� � � � . .- � - _:-. .. t heteby af#irm that thara is a conshuctioo-le�ding agency�fw . .. . - -� � � . . _ � . . . .. . � . '- the-performvnce of�he workfor which this perm�t is iswed - � .. .- � , . . .� - . . J (Sec 3Q47.Civ_C.f. . . � . , . _ .. . � . . � " � . :� . . . _ .. . . - i . _ . . . . . _ . _ . - _ - . . . . . - - - . -.. � ���. � Cendei s Nqme - � - � � �- . � � � � ' ter�r's Address. - . . .� � . � . . . . . .. ... . . � . � �� I certify thot 1 have read tbis opplicoiion and sta�e tha�the - � - � - � ��� -. , - above.informotiow+scwrecx,I�agree��ocomptywiFhc�k6Courdy . - . � � � � � � � � ordinances ond Stme laws regulat'rng Plumbin9,and here6y � - � � .. - � - � outharize representafives of ihis Counly �o enter upon !he . . - � - - . . �� � � above- e�tionecf property �nspecrion purposes. SEE REVERSE FpR EXPLqNATORY lA GUA __ ��.: - __ _ i - Sig t oi Permittee .. Da�e � . . . . . � � - � - � , . ! ; m-6 . . �. � � ;� _ T� 0 O+"O . . ' . i,i Z � C p� � O . . � -Q G 4-.Ol �n � t-C' .. � . . . . � O p,� � . p p O� p A . . � d �� d d u p C� � Y � a Q.O � �� •S•-r- .: ' . N ,r;�� o "3 o u� o �t o ..�o.o :� � �� � � . 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