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1206A (6)
. _ _ s4 �- - WORKERS'COMPENSATION�pEGLARATION . . . . . _-��Pl��Fi�tOrV�FQii-�LU���i�G-/���CIYIrT� . � � ..�-� - t hpreby affirm that f-tmve o certifitote of�mnsent ta seR��� �bq667A - . . . . - . . . - . , . insurB,�4r p Gerry'ficotG.pf Workers'.Compensation Insurance, � CE 8U(REv.10/81) � -. . - . - . _ � � or a cerkified copy thereof(Sec. Lob.C.) � - - � � � . � r � COUNTY OF LOS hPIGEtES BUILDING AND SAFETY ��� ; PQaltcy tJo. -. �mp�,y . - . ,_ . . ` :Cerhfeed copy u k�aiehyfurwtaf�ed.=- - --. .-__._ . .. _. - - - - roa aere+cnw{�o�+�t iw{aRiw�oz�aey :_ aw�ntr�c. _— � -- __-_._. .. �Gerrified cepy ts�tetact vstth ehe ronmy burtdtng-7nspec- -. NUAnaER�:. ....FlS�iuRF oQ ireas -.. noU2ess - ;{: Oa -.. . . tian departmenL _. _ _ . - � � tOCALCN� . . . . - �-�te •�Appli4ant � . y�-_ WATER QfJ5E7 - - � � NEAREST '�'-'*��-. � �. . . � � ��� - .-.--.CER77FIGAtE.4E.EXEMP�t4I�FRQhh wr�arcac�. .. __.. �,'_ eair�.N6._ -._... -.__. .... �._. L� .�—. CROS5 ST. .7 _-.-, .. ,... -----COMPENSATt6N}NSURANCE -�:.. . . .- . � . . :� I QWNER- �- � j . (T1lifEAEtIORFiwh{-7�'LatCRIpIYhd�fluwrrk-�ernlvadll�.� - SH6WER_ . .. . .- .. _ . . . . . . ...� .. the pQrrat3 i■far�_cnff kwdr_a.d dolloes j�100J er�eft;� - �4ynTORv � � y uwLL. � : .____ ._ ___ �- -� . . F� �� ADDRESS -.� 'Q�,(f . ' 1 certi{y thot in tFse perfaem€�e of th�work#ar wfiicF tAis . . . .. . . . � . . � . -_ _ __- _ SfNK . .�- C17Y ♦� . permiF-is issuei3 t sksctfi-not emptoy wty�person�'rn-arrysnar�rter � �f/jr_� �� .� -TEI:NQ.�. . . . so as to become subject to the Workers°Campensption Laws. �DiSHWASFI€R � � - - � ["��7"�Q� � � .. � . � t� CQNTRP.CTOR �'�.� . . . - patn nr���,���.1'j - CtOTNES WASHER � - N �� 'E TO APPCICRNE: if,-afte€makuEg�tltis CerFifi€ate af - .. . - AD4RE55 .. _ ' - E� Hon, yeu--sheuld-besai€+e s�t te't�--SAEo�kars` ..: , :-- 51MtA�M�.AE)L3E BEG�REpR ,�_ . � . '<:.� .�.--- . .--.' . .. _ - � .' . ,-:.�. - ;;..-:.� � Compenwiiort pravisions o€Ehe.€alaor Cada,yov must farth- - ��n � � TF����� . Ul'A'KSPRINKIERSYSfFM � - . . ,. with comply with such provisions ctr this permif shul! be. - . STAT€ � . ��5$ . tr deemed revoked. � � � WATER HFATER ,� ftCEKSE M1tC3. � . . i�c�vsEo carne,acroas�cua.�ria� o,s��cr n�� +�sss�ar F hereb aff�m.lha�k am fEcensec#cmder � . :. -. GnS SYSi€Aa ���.�LXIrLEFs.-� �-. .... � � �_ _ - � - Y provisio[rs of�}ippker 4 - . . (commencing wFth��fion 7G06j oF Qivision 3 of the Buseness � �t�fEEFs pyEg . -. . � . . � . and Profe�sfnns CQde.a�d my_.license�lrtfsdt fnrceaadeffect . . 5 PER SY�IEM - . . FfNAL �-. ._. _ ... - �� � .Cicense�Number �. _ +a-: -tic�Cfass'_�...W...... � .� _�, ..:_,__. ..:._ _._. � .., AAif 1;i: q !""'' . . . _ ... . .� u--.� HAt1Q It3N � � „'��� � . . HNAt r- " . .. � � -� Centcador - QoL . 8Y . .. - . .. v . ❑ I�arti exempa unde€Sec, - � .. . -� -. � .. . � - . .. . . tu B.BA.C.for rhis reason _ PIa[t cEkeck#ee : _ � _ Z � �_ Q �t2Q6fi � � � -� � � � PLUM&!NG PERMIT t55UING Fff S - - -- Siqnatur .. .. - .. . - � .. � � _._ . . .. - :�. _T6TAE FEE .. -�. - . . . fF� n. . .� . � " Plan check applimnv ---.� - � SINGtE FAMtLY - I • •�FL rJ(1 , -� HOME QWN€R$Et44t)ER DECLARRFFQN -� Name . .. _--`_ ;.._. . � .. _ r.� -� I� iy affrtm tFwt-I am axempt from the Gort�actaCs ticense .�� :. . ' -- — - -- :_ __ _ = �"-�--�£ ��- . P�essi�w+}er`af fhea�o� �I�do the work and�he .. � CAckfress .- . Te[.No. --� ` �. � '- .� ,�•� ���- � Q'j�Q g,"�J� .��� oiFawA*9 f � �fi" k . - - sKuciuce is not intended o�affered for sole(Seciiori - . . . . .� . . . . . _.� . . . . . . � 7d44,Business and Pro€essions Code}. � � - -� -� , . � ' - - � _ - .� ;��-.. � � CONSTRUCiION LEN6�NG AGENGY -.... .. .- - . . . . . .. . - . . .. .. . � F here6y af€irm ihai there is n caestruction lending agency for� � -� - _ � - _ - - - - � - .. - - �� -_ � . - i,. the.perforrtwnce of fhe work for which this permit is issued . , - � .__�_. -� . - � � .. � - � �-� � .. (Sec.3047,Ctv.C.}. . . � - . � . - _ . . � . . _ . � . . . . . . . . . . . �Cender`s.Name.. . - , � .. . . .. . - .. . .. - . . _.- _ . - . . .. . . . . . . . . . . . . � � LendersA�dress .. . � .. . � - ._ �,. . . � . �. � . ._. - . . .. .� � �- 4 cerlify tha+t.-have read fhis npplkation and state fbat the. ,_ . -. . .� - . - . - -- above.in#orrrwtion is correcL!c�gree to compty wi�h atI CouMy- - � . � -, . . - . . - - . . � ordinances and Srore laws regvlating Plombing,and here6y �� . � - . � �� -- . : autharize representatives pf fhis Caunty to enter upon ihe - � � � � . � - � - . � �. - - -- . : . � ( , � �� above-menlianed prope for inspection p�rposes. -- - �-� - ' � - . , � :" S�'� tS� SEE REVERSE FOR EXPtANATORY tANGUAGE � . +h .. . . _- ... i ature oi-Fermittee - - Date . . . �.: ._�- . -�� . . -. . - . . . . . -. . . .. _ � �_ _. _. , -- �:� _.._.-__.___.-- , __�.. -- * � � T•C p O.0� ' �. . . 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