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HomeMy WebLinkAbout1223A '.58 WORKERS'CQMP€NSATtON DECLAR.4T�QN . � �pp�,�eATIQN FQR PlUMBIW�G PERNtlT � � . I hereby affirm that f have a cerffficate�of consenl to self �yqybTq - � � . . � - insare,cr n tertifiwte of Workers'Compensatian knsuronce, CE 877.(REY.IaBlj � -�- - � �� . � � - � . o❑�n d copy.oher�jr,�c.3900.Lab.C.} � . . .. . .. _ _ . -� '�-�� COUPITY OP LOS ANGELES BUltQ1I4G ANQ SAFE'fY � t��f - P ii . . GQmpany i„[!'��I�"IQ:�S . . _. . . . .._ _ - O��� _ . � Cer#tfied copy ia hereby..furneshed..., � ----- --- -�--� -�� �-�-� FORAPPt�CANTTQFtLUtJ(PRIN70RTYPE) r'1 ..__ _.._... . . __ .- �Certefied copy�s filed with the courcty buildin9 inspec- .. ADDRE55 W � - NUMBER FIXTURE OR IiEM �aat�n ftOY1 d8¢RCkmeiH_ _... � FEE - � '�] �l� WATERQOSET . ` i�- 6ate_•V�AppT74ant/TZI�Y..� � - - � � NEAREST s . -�C€RFtFtCAiE6F-EXEMPFIONFR4M"WORKERS` _ �L'�� BnTHTuB - . . . � , CROSSSF. . (f . �'. . � . - ..CQAAPENSAFIOM1t INSURANCE � - . � - .� - � SHOY¢ER- . QWNER - . (ibia sectlon�naed nM-6e�t � - . bY.:--. . ._� . � MA� .. � .� ♦ � . Y � th�pe[mlt.is for onM 14�r�d�ed.doFlars'(S1�)ar 1sss:I � tAYAtORY � � �—' n�oaEss '� . t ce�tify ihat in the perfarmarnce of iha�warfc for wFich tFris � - �p . . . - ' permEt�.s�sured,.t-sl�ou.aosemv�Y-�`Fe��so*,-,m�ny-.+wn.�e... . �L._ surK. - - � y -� c�rr �_[- ,� � ' - rH.rao. . ' i�Fftfl - so c�kt.6ecoma�ulz�es#to the�Wcttkars':€cmpsnsat'ran tuwv . . . - . . '�� .. � . . ._ __ .. DISHN[ASHER .-.f_ •r__CQNFBACF6R � _ . . . . . ,Q ..__ . . .. n�,���-:�-$S`d �.. _ -: CCI�`l`� � �,:kcs,nz c�o€t�swa�s�� --- _ �4 '� anoaEss �''"`CE T9 APPkEG4NT. If. after makiA4 th3s Ce�tit+cate af Swrrovattt�K'r�P9Q1 RE. r� �.., .,,.� .,..,.. .,:„. _ g,_ _. .; .,, . ,.- . . � ptiiaw. You-..sFWUki-l�BGitnte SuhjeCi Eo_.3Ere.�Nisrk9rr` - , "> . ��?aA, � . . ,.-� ., . : . . �:,-, � . Com enwtian � ..:` . � � � cirr :. � T€t:hIQ. � p provisiw�€uf.rFie lubw�-Cacfe.you musr fwrh- tqwwSaRErtKtEssrsiEtn .. with comply with such provisions or this permit ghatl be - SfATE �j + .ttC. � i - deeR+ed revotced.. . .. warER HEahrr �rcfNSE No..�j ( Q cwss . ! .- ,. LtCEN5E6 C6h1TRACTQRS DECiARATI�[1 - ot57kl�i NQ, � - PR€,fEE55EU 6Y � - � .. t hers:by riH�tm-that Lom Iicen.saelu[rdet{xeaei&en�erfGhapter 4 . - GA5_SYSTEM ��QUIlE7S.. ..� . . .. � .. � . . �CQlRRf@iiC�R'i�Wtih.�f Wh Z�Q��F{�IVISfOf}�O�1f1�-�Si�1CS5 . QUFLE?$OVER . . . _ nndPr�€ssswnsEode.ondmy�l�enae€t6nfu41fvtces�deHecr. . .._ S�ER-SYSiEAt ---- � ..__�___ _.._- - -__... ....._ . . . } ���� _._ Ftnrnc Y tlDAfldN °- _ , ffatf¢;` t:F ���, p - bcense�Nurtrbe �ic Class . • . . y . . . . t � - . ���" `� .. � � � .. .. - FtNA�_ - . . . . _ ft. . -CoNract Date�J�---�C� . _ . . . gy �'�.,�._.__„�...._. . . � V . Q- f am exempt vnder Sec. . .. . . . . . . � . � . � . - . �.. � �B�.BR.C-For ih�s reoson . .. . -. . � - � . . . . � - �; � Plars check fee � _ Z .. . _6ate: . . � PLUMB€NGPERMITlSSUINGFEE � { . .. . � .� �_.SignatuCe - - _ � l� C _ . , � 2� [[:�J!� . . . . . . . - ,..� .. - .... - . .. .. r.TO7AlFfF OQ 34� . . - . - . . _ . ...��: i•.•a�. .. - ��- � . . �� .. . Pivn theck applicant � .. . . .. . . . � '-_ . - SINC�LE FAMfEY . . . � . . .. . - � -. . . . .-1 • 1 G Q 5 0 . . � .`...,�:HOMEI3WN€R-6lHCDEROEL'tARAT10N-,�---.. ..... . t+lame. . . . .. . .. . � . . . . � �gafhrmitffitlamexempthamtheGonnactw'slicense . _ .. . � �;_��;=�u,w� ..� qddre�s�.�.: ._, �._-_i ., .--_:a >.=�a . ...' ,...�. ,. <t.: , _ :�.: ..: .. _ �,�' , �_.�'� . ,. .. . t�. ror ifie#otlowing`reason-{$ecfiori`7(13T.5,_Business and __ . - �g_���v� - Professions Code�: . . . City . Tet.-No. � � - . � ❑, I,os awner of tha property,witl do fhe work aritf the . . .. � � � � � -- -- � . _.. - s�ructura is not-intended or offered for sale (Section - � � - , . . - - � � � - . - � . � . - - . , . � . . 7p44,Business and Pmfessions Code). � . -- . . . � .. . : . �� � � ' CQNSTRUCTIQN LEN6tNG AGENCY . . . . . . .. � , . .. . . . . . . . - - . - f hereby offirm.that-xheraua cansiruction tendiug-agency tos.. . � - . : . � . - � � . . �..� . . . - the�perfo�mance af ihe wotk for which ihis permit is issued . . � -- .. � � �- � - (Set:.3F�1.Civ.�C:). � - . .. .. . � . - . . - . - . . . - . . ... � - . _ . _ . . . . .. . . _ , . - - - . . � Lendec'slvame _ __. _ : i __ __ ___ . . . -- � Lenderts�e�ddteu � . . . . . . . � . . . ..- 1 cerlrfy-lhoT Thove read this appticatidn and state thaf the . .. . . . - .. .:� � .. . � .. i abave infarmotion is correcCt��ree t�scb(tsply-with-qt�-Coumy=-:� - - � . � - - � . . - � . � � .- ordinarttes and Statelaws regulaterg Plumbing,and hereby - - -� - .. � � � - - � . .. '� authorize representatives of this-County to enter upon the - - � �--� � � � - � . � . � � above-mentinned property r inspedion purposas. . . . .� . � . -- . �.�.�. . .. . . . . . . : SEE REYERSE FQR EXPI,ANIITORY U►NGUAGE -t �- 5� m� e o Permittee - Dote.- . .� . .. � . . � _� . .. � . .. � O'� �' N �.'. "_ �wN b � C�L O �. Q ] C,�w� ' , . -�„L .p � � Q.D , , N �V : ,,a^ ; o y IIi o rna� �' � � y o'^'`'n o� . WM - #" � .:c �' a �' � v'v"�.. „��„.c ' ° `�.p .� '� � ° ...0 � 0�,p�..MO N.:,m O C � N > �� Qi L O� ,["fl Q�^'� ' �'4 n' . � +,L 6 � D V O � � uNi �� O m x ,� a 1- Z'� .£ + O j O � � . . . . Q �E � a' E �� �a M••`�-o� e '��.-0 3 � � > ° Co -� �., o-� om a ° pi. �"o�a,;� m > �- ¢� �'�muo ° E3aOy �' ` ao t a v �"E 6� � ae�, c a� �Q a� m o'.�i,$u'� or° � 5 ae. m �o � �i�e��,�f, ° y c ° c ° �im os n m r� m o , ouw a� �.,.� x o�,.. °-�',� a... 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