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HomeMy WebLinkAbout0877A (4) . --�JJORKERS'COMPENSATIOM1t DECIARATION APP4ICAT�ON COI� PLUM��NV.:PER11[lIT !-1 . _ ._.. .'-__ ' . 20�W2b DPVJ 4lET . . . . . � I hereby,affirm•that I have a cer8ficate oftonsent to selt in• ���a _ - s'Lre,oracertificnteofWorkers'Campensationlnwronce,ora .�ga7l�y:"g�gp) --. -- --.--- --- - _ . _ _ _ , � . certif'�ed copy thereof(Sec,38�Q,Lab.-.Cj- . ..�-. . . . _ _ COUNT\'-0F LOS ANGELES DERT.OF PUBUC WORKS . Pnl{cy No - � --Compdny� � � - � - . � � � . - ', �-Cert(fied copy�s bereby furrtished:� - � . _ � . _. .-... -._. � . . -.� . . - ' - fqR APPLICANT TO FILL IN(FRINF OR TYPE) 8�����'��- 7,� � CerNfiedcopyisNledwilhthecooMy�butldirrc3'rnspeclion ADDEtE55 �/♦ L .cJL . ❑_d������� _ �,_ _ NUMBER flXTURE OR ITEM � @ FEE ��A��n, � . � . .. � . i.� WATER CLOSEL ITOILEf) � � � (/� - . . �'i Date ' ' - Appl�cnnt - .. - NEARESi . . ..--CERTIftCR1€6i fJCEMPTfON FtK3h1 WEN2KERS-" - - .BAFH Tt16 � CROSSST. _..�" . /�.P�im' .. . . .--,.. :- COMPENSATfON iN5t7RaNCE -_.. ...r � �10WER - . . . r � . /i � OWNE& � . - . jTkis�agctfon noed nof bQ eomptafqd H tho wwk Fnrolxed by . �p . . � : iM �it is(or ww huedrtd do4�es(#�7flB or kss.1_ wvf,roar t�.ai� po } ( � nooaFss f.J G.- CG� - �I.Certify fliat in the�rformance of tti�work 4arwfii�t#iis per- _ SiNK . . . . mit�is issuaci,F sFaff not employ any-Nersort ew any-.mcsnner so - GtTY �TEL NO.�� �`� ` -a4-to bec6me su6jec#to the Wwker'Co��en5atibn-tows � � � DISHWASHER -- � _ _ .__ / C6NTRACiQR__. _ . - � .. _. � Dofe.�'�r�pPAiim � R-t'j . _CIQTHES WASHER _. . . f . NOYJGE-T6 APPtIGANT,if, m n -fhis GeNr#rcate o€-Ex- ._ _ . . ADORESS B� !� G%L �'�� . g._ �-- �---�- ------- ____.. . _... .-- -r - SWIMMING POOL RECEPIOR emption,ynu�sfioii[dbeco e eci+a�Nle�Ws�fcar3�ompen- CkTY � TEt,NO. so�io�t�prcrovisions of#teiabor�Code.Ye�masi-furthserith comp' �p,Wtv SaRtNKtEa SvSiEM � ��' �6`��� - ly wiih:sucM provisians ac this�permll shatkba deemed-+evok- - SiAFE � tIC: � - ed: . .-. � � WATER HEATER . . LICENSE NO. - CLA55-� -- � �UCENSED CQNTRAC7QRS DECIARAT40N �D�STRKT NO. PROCESSE6 Bv . . ..khereby�offirmthWAomlicenseduader�or'rsronsotChopiee�... GASSYSTEM OU7[ETS� - . � . . 9(commenc�np wi�h Section ZOOQ}of Divisivn 3 c�f rktie.8usiaeu� - �- � WitE75 Ov€R - - - - f 5 PER SYSTEM and�P�'ofessitins Ccde,and-my lrcense-is in F�fl force-and ef� - _ EINAC � - vA�Rbr{t}� Y . fect. f�.!�/ q ri - �'} �-- - � - DATE . a � License Number- �7 7"�� ?J-L�c�C�ass +� � ��� - � U FlNAC ¢ � � -Con€rattOr-����-Otlfe... .� - ... � BY _. . Q r . .� .1 am exempt under Sec. .- . . � � - � � . . W� B.&p.C.for rh�s�eoson Ptan check fee �, � � Da : - . - - � �PIUMBiNG PERMIT IS5UING FEE$ �} � . � - . � . sre�or��e toTat Fee � �Q 8 Z 7 A - . . -.. � SINGLE FAMtLY Flao-cheek apptrmnt - � #e • • - � E�OWNER-BUIGDER DECLARATlOPf � - 6 °" . — 1 hareb affi�m:thot I am axem t from the Con)ratlor's License . - Law�far the-foflowing ren5on(Section 7037.5;Business and N��e - �� � � t.+ •'J 4{t� ProfessFona G9de): � � � Address .. _ . -� � . . . . e r e,:r 4,�!'ty�, . �i,as owner.:of tfie praperfy, wi�l do the work and fhe �Fh �^�` - Te�.No. . �_ . siructwe�srwi'rntended-oroffer�ed�fo�sa�e�(Section7044;--.. _ �.... . . . �FS.� J—c%d -�t_Business and P�ofessions Code). . � .. - ► . . . . . � - � CONSTRUCTION LENDlP7G AGENCY . .- - . , . . - � . " � . . . - . 1 hereby afficm that ihere is a tonstruction lending agency for ,�- � . . �_ - � thepeho�mance of tFe work for which�7his�permii is issued- � � -� � . - � _ - . {Sec.3047.Eiv:C:). lendei s Name � � � . � � . . Lendet'sAddress-._ . � � . . . .. _. .. . .� � � �. . . f certify that E have read thio npplicotian and-state thai the� -� � � ► - �� - - above informotion is correct 1�gree to comply with al I County _ . . � ordinances and�Stme-lnws�regulating�Ptumbing,and hereby- -� � . . - ��-- � �� � . � authoriae�represeniatives of ibis County to enler upon 1 e � _ -- � - above-mentioned properry for inspettion p�rposes. - -� -�. � � � � � � ��5.� SEE REVERSE FOR EXPLANATORY lANGUAGE I � rttee � � Dote� ._ . . . . . . - . . 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