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HomeMy WebLinkAbout1197A � W6RKER3'COMP€NSAT}OMDEGIARRTION - - /yppL,�CAT0O1�! �O�R R!lIMBING PERMiT - �a 1 hereby affirm that k hove a certificate of consent to self �yAy��p � insure,or a eertificole of Workers'Compensotion lnsurbnce, CE 817(REV.sp/g).} � -� - � .. � � - w a cert�Eied copy thereof(Sec 3860,Lab.C.) COUNETY pF LQS RNGELES BUItD{NG AND SAfETX � �` � R❑olicy No.�fumparzy ... - . . . .. . � . . � . -- .. ,-_� � . �iedcopy ishereby furnished.� � . . . .. .. BUtLDING - - .. . FqR APPlkCANT TQ fFLL IN(PRtM QR TYPE) Cer4F€i�d copy is#ilec#wilh tht county building inspeo ADORE55• �. Q� �` . �- tinn�depnrlment.- � - NUMBER FIXTURE OR ITEM �y-� - FE{ . . � . ' pn48 ����� p�{i�n# �!]��.�/�.. .... � � {� ..� IOfRLitY Q� . . . .. � .. �, , . _ '�.r_ WAiER CLOSET. _ NEaREST . . ` CERT1FItAt€OF EXEMPFION FROM WORKERS 2. eatH RJB - -.` r,,,CRosS 5T. � ,� � ( ���"/�tI � - � - -- COMPENSATION It�tSURANCE . . .. . . . - -_ — _.� _ .:_. . SHOWER_.. . . f3WNER - - . (Twis.xfiwc.wa�a�w campM.`.a if�k.woEk brolwa FeY �he ptrmlt ts f�oaa Mmdrad doNers(5100)w bu•� ��, uivaroav t�ta.i� L -- aoo�ss � ! /fft Zj f serEify that in fhe performcmce of tFce-work for whlch this � - permif-is issued.�t shalf no#emptoy any persort�n ony�manner. . . . StNK.. .. ._�� .-- ��� ^� fifY-�� �! � TEI.NO.-. . . . . _ sa as to become subjed b the Workers`Compensafion Laws. .. piSffwASHER � � �- � - . � - ... .._ . CONTRACTOR � - Date 7����li�t ,�111/C��h�_ c�4�t�swasa[a --- _ s� iCE i'f7 APPL.tEANT;ff, aftar mak�ng`ifiis'Cerii€imtn of - � -- ..._ -- A��`$ .--.�„r�f f�" . i- T�pkian, pou stwuid betbma syb�ec€ ta t6e_1M�kers -- �MING�RE�PFt7R .-` . '-- - •- :- -- - - .-.__ _ - - ,: . . :,. �. ,,�.- . ..-�. } �c.mpgrsspiion provisions afi iRe Co6or Code,yav m�st fartfi E,e,yry�RlNKIERSYST€M c� ������� � '. witb.-wmplY_with suchprovis+ows or�ihis permrf-shalF be . . . STAiE - - � LtC. � deemed revokad._ - _ -- _ , wnrca HeAreR ,� ��wse ria. c� � - -�- .. LIC£NSEEl Cf)NTRACTORS DECt4FtRTl4N � . . `� IItSi2��r wR. � � PROCFSSEIS sr � s. t F�erebp afFirm-tIwRF am ficansed underproveuans of Ehapfer 4 �� - GAS SVSTEAM1 (}ttTtEiS � � ..� . " � ._�� - ... . � . �; (cammenang wiek Sect€Qn-7pp6}af pi�ksion 3 of the flusiness :. .. - ouF�ETSpyEa � . . .. ... -. - and Rafessions Code,ar�d my.licertse is in fu(I fwce_Qnd effeci, 5�R Sv�i€M .. -.. �} - -.�. � : ' FDare �� �� c�� VA ATION � � ticen�e Nvrnbe�t�i�e,�`7 iir_.�Inss�� .�� ... .. . . . . . . --� � - � ( -� - . - --- V �{ t�?Ll�F.1/ �,[ Ff t _ a eonra.cmr�/-'�— tk�re-�, �y_�-`"�J=- _ _.__ _ -- . . Bv ---- - --� --�-. .. . . O i P � _ _ � f � - t am e�mpt urider Sec.- � � - ... . . . . � - - &.8F C.for this reaaon � � . .. � . � . .. . . . y. g Ptan check fee � � ' - Dnte: .- .- .. _ . . _ , . . •- � � - � � . - PEE1M8tNG PERMtF 5SU6tdG�P€E� � �_ - � . . . .. - . . . 3ignoture- - . _ � . . - . � . . . . . .... � -- . � .. . TOTA1 FEE. .. � � � - - �') � Q�J A ° . .'. _.. , . - Plan check opptimnt- -- � .. . . .. .-- " - . . . . . � s�rv��Fannuv �. . .�..5 . HRME OWNER-BUtLDER DECEARATIQN Name - � � �faY affum lhct t am exaEnpt from the Canaader:g License -. . .. ... ,. .�_ . . ::: �� ,f�..� .. .j.:►t 7�i FJ>(}�.� . -`- L� for the fol7owi++g reeson-�fSection-i€33i.S.8vsrciess nrtd �_- ����-'--__. . �_:: ..... .::_ _. _::: . .-..�. __ �-�.-- : �_- . _ , _ .. _ �� . Ptafessions Codt): - � � Ciry � Tel.Nn. - � - - •�` 6 ! �.rJ L c$_+ . a �. � �- �I,.as owner of ihe P�operiy,will da the wark and the .. . . . .��'��g�.:.� ,Jr � _ - sirue{ure is nof lntended or offered fw sale(Section � . . ' , � . -� , - � �� � � . �<� 7044;Business and Profeisions Code). � . - � � - . - - � � �. -- CONSTRUCTION.LENDINGAG€NCY � . .- � , � . - .. - .;._ :-- - ..-.. . .. . . � � i hereby¢ffirm that there is a construction lending ogency fw . � -...- - �. - . . - .. - �.- .. . . , .. . . . E the per£armanca�af the work for whlch this permit is iuued . � . .. . - -- - � . .. . .. - � z��' ($ec..3Q47,Civ.C.). : . . _ . . . __ .. . � . . . . _ - . .. . . . . . ..-_�:-._.. . . , i . Le�er's-Name� . . . . . .._ . � . . - - . � . . � - - a . .._ . . . . . . . - . . - � ' Lertder'sAddress _ . ��.-�� . ....... ', � � . -;: ___ .__... ......._- ---. __. .. . !rertify that f have reod this application and state ihai-rhe � � . � - . � ..-- . � - . - . a6ove-informpt4on is wvect.1 ngree to comply w�ih all County � � - . . - - _ � . - �-ordirrances artcl 5tate laws reguiating Plombing,and hereby - . - - _.,_., .. _ _ . �-� , .. ou�horize representafives-6f'tfiis-CovriFy`fo eriter upon the . . . � . . � -'. -� -- � . . . � �. � - ab¢ve•n ntioned prnpecty f -inspecfian puopoxn. ---... - . . - . . - _.. .._ . . . ..- - SEE REYERSE FOR EXPLANATORY F.ANGUAGE � �- T� . ... . - . . . � . . .: . . __.__ . . . . 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