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HomeMy WebLinkAbout1211A (6) � � WORK€R5 EQMPENSATI6N 6ECLARATION --- � /�pPLICATtQi11 FOR PLUMBIiVIG PER�l1tT � � � . � � 1 hereby af4irm that 1 have n certificafe of consent to self �- 76A667a � �� � � - . insure,or a certificate of Workers'Compensation Inwrqnce, -CE817�REV.�D/91) . � - - � � or o certif�ed copy+hereof-(Sec:3800,lafb�.C} C�lJP1TY OF LOS ANGELES BUICDIPi4'ANR SAFETY � """��,b _ P�ol�iry No_ - Compcany��1 'L mQ«� . .. - . ... � - �� � . .. � y. . ,., Certifi�c#copy is hereby fumished. - � � � ', . FOR APPIICAM TO HLi M(PRVNT OR IYPE� qD RESS� QC,FI • � � , ' �.Certified.cogy.is.fiVed withlhe munfy�uilcfing insper �. . . �.. � fian department. - NUMBER ..--.FIxF'URE OR ITpM. � � �� LQCAIIFY �. . . ���_�a��;�o� ��C��n 'a, war�Raos�r ��.- ^ r�eAaesr F' ±��y J� - ,�,_, EROSS ST. V f vt t J '��J . -� EERTtFfUiEOFEXEMRFI(}hF�fRQMWORK€RS' BkT�+TUg� �- - . � �� � _..-COMPENSATtONtiVSURANCE- - � . oWWER . . . . ' (Thls�seeHoa nefd�ewt 4s co�ptQMd if#ns�ror6c-k�w&ed by � SHOwER . . � .. . � . . fks pormlt is-�orts�Auadred doltors(�l�j or-kss:j - - - .. ._- tAVAT4RY - � �. .-- �ESS 4.J + '�W . I certify that ia the per€ocmonte�.of the.+trQrk for.which�this . - . . - ... permit is issued:-F stwtt not employ nny persor�in ony-manner � � �� - - - . . �.� � GITV eQ�. . .- SEt.t�. � �so as io becorte suhjxt to the Workers Compensation taws. - 61SHWASHEB � . - ��� � . - . . . . . . rj�� �"n1�n (,�r�A '� U�NtR,aC70R . Date�J �"�./ a t.� „� fT..[tC�6l�.�... � CtOi}+FSwJ�SHER � �` AQDHE55 _ ... -�- . �Vt�rtCE TC}RPP4,lCAhti. 4f, after making fh�s CerFitica�e of ., ������ .- , � � ptian. You.��shauld becort+e €vbject to the-.:Wwkerx' ` __.._ �.�.,.��'... � .. .w. . . � .- .--.,........_._,—�- _ Y�= � - peasatisraprarisiovses��tabar'�ade;ryrntmUSPfbriF "" ..'E'�"'. ' -' '[H;[�t`-^"""._.. .."'...," - wit6-comply wiFFr Su[h provisions au !hn permtt shall be f, IAWN�RINKLERSYSTEM SSAiE �:. /�►4 . UC. c-�^.- . � deemed revo4ect.- . .. .� WATER HERF€R LICENSE M1K}.- �.! ctass ;_: # . --.. LIEENSED CONFRACfQRS DECL4RATION � . . .. � Obsi2rCr(�. Prt�C�ev - ( . I[�ereby aff4rm ihat!am iicensed�nder prorisions a(Clroapter 4 - GAS SrSTEM ,� � 6UTLE7$ - +�.�� �� �.. . . ." � - (commenting with Section 7�0(t)of 6 visiort 3 of tfie Business �- OIfTE€TSOVER �- ' - � � ° � and Prafeu�ons Code,end_ lAsense is in ful!€�rce and c . S PER.SYSFEM . - � . - �" '' �((( R ���^� vnu Ar�a� d ' j�,{�7 ++ .-,. _. �. .. . DAT€(�-".?Si- ,�.y`.e-, - U� � - license Num6er��L.L(2_L�Eic.Cfoss��� `��� . . � � E .�_ : _---7_s .� . fIN - : .. . Corsfractar. .. . . [#nee�� � - . BY . � . . . � � _ ❑ i om exempt under Sec- . . . . . . - . _ .. . . . - . . . � � - .8.8P.C.for ihis reason � . . . . .-... . � � Flan check fee _ � � : .. . ' . . �Date: - . .,. . . - PIUMBfNG PERNd71SSUfFIG F€E S ..�Q �.� . . . �� -. . . � � � F ..-�Signature - ._ . . . .� . . . . . _. . .. . ,. TOTA!FEE... . :- �'- .. . . .. �� �.�:� R�. g@g@g@ ... ...� .� .�. ...-- Plan check opplicant . � .:':� ..-. � � �s f �-� i�j [ � ' StNGIE EAMILY. � - � . - . . . � , .. � . � HOME OWNEk-BUIL�ER DECtARATION - Nome . � - �,�y a�;�� --' � !` �bp offlrm thaf t am exempt from iha Cantroctor s License ��9�_ - -' � �- -. -. . _. ----_, . _.:�...... .:.: . y.e,� �.. . ,`_�:� E� or khe€oNNekwt��EOson:{Seciiet�TS}31.8.$t�siciess arrc# - - _ .._.�._ - . �� Z�G..t7 c. � . .r .. -z.�.... ». -�,m ,,. ..=. �...�,�. > Rotessions Code)' ... "- .� Gry Tet.No. - � . .....- . .. � .- . � . . _ .. .. .. . .. � � _ � E,ns awneco#�he prope�iy,will do the work nr�d the . � ' ��•�4.�-�'��. - stroctwe is not intended�vr offered fo.sale{Settron . . - �� : . � - �� - - � �- 7044.�@usincss and Professions CQde�. � � . .. . . _ . . - � . - - - - ._ -_ � � � - CQNSTRUCTIOPI IENQING AGENGY �..:..� . . � � .. . _ � ... - � .. . . . . . f herBhy offirm that there is v conshuction lending agency for ... .. . � . . -� ... . - � � �_� � . . � - the perfacmnnce-flf.the work for which.thfs-permit�is issued . . . . � . -_. : . . . . . � -. . - . . (Sec 3047,Civ.C.j. � . . . ..- . . . .. - . . � . . . - .. . � . __.. . . ... . . . tender's Name - - � . .. � .. . . � . . . . ... . � .. . . � Lender's Address . :. � - .. - . .. . � � � � . -: - .. .� � I cerkfy�hat I�have read Fhis opplication and srafe thot�he ._ � � - . ��- � . . � - . . . - abova information is correct!agree to comply with ai4 Caunty � .. . . - � � . � erdirwnces and Srate laws regulaiing Plumbing,�and hereby , ` �. . - � � - �- -� .. � authorize��epresentatives��oE��this Co�nty to eniet upon the --- -- _ .. - - -�� .. � � � a6ove enfiorred pr r inspettion purpos��� .. .__...�� . � �EE REYEft,SE PQR EXPtANATORY Ll�NGUAGE ( � r . . .Sig ofPermi ee . . Do]e . . .. - . � � � - �- � � . . . - ._ � - � � I � _,. ro v �.� a or-q L • v, G "b C ,O�p n � � =s . , � :�. d � . m ° °-` ° ' 1 �o 0 t p p, .. .O v1 U'�in N O, O p)p. m N O.G � �ti-'O �.!]fl,�•-� . . . ' ,'�'�. 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