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HomeMy WebLinkAbout1205A (6) .� . WORKERS'C6MPENSATION DECLARATION . . QP T$ [� p �A R! R .. -- - �S � '. 1 hereby offirm thot I have a certificote of consenl to salf � �` _`-�����``O� �i� • ��•fi`�•�� • ����� 76A667A . �_ insera,or a cert'rfimte of Workert tompensation Insurance, r_EBt7(REV.19�8Fj � - . -.. .-.-. - � �� . � . � � i e '�ed copy th�reaofl$ec. b.C.) - . .. - . .. . . - . . � � �.S ',.. �^��P � `�},� _ -- COUNTY OF ld5 RNGELES BUitQING AND SAPETY � - �o ecy oi..O�C mpony l�'�s/,Q . . _ . . : ' _ . ._. .� Certif�ed copy is k�ereby fitrn3shed, . �Certi4ied �sfikedwlthfhecoun buifdin FORAPPIICANTTQFILLlN(PRIM�RTYPE) BUlLDING - � - �� copy' ty g inspec- ADDRE55 � - tiort depariment. �� � . NUM9ER- -FIxFURE 6R fTfM� � - �E L�CALITY ' /��" � � WATER ClOSET ,� ' �- Date t ��pPP{F4anf���� _ - _ _ . . ��" NEAREST -C' i /� '� i . �-CERfIFtGATE C}F EXEMPTKIN-fROFR WQRKERS'-�-. .. �T.r' BATrtFUB . � ...,.� CRfx55 57. t.7 Q ly� . .. .... ..� C6MPENSAFIOFI-tNSURANCE-... . . . . � - . � - _ � SFfQW€R 4WNER � � � - {Fhis sactbn nwd+rot be compisled i#the xesrk�i4eolwd�6y � : . : �-7 - � ��.-7 _ - . Nro_pvrmit is fo�one huadr�d doUors(�leQ}orf.n.j - uvatarr � � �. aoo'aEss ��-0 /� �Vd e 2tiJ E � . t.certify that frt the perforrrwnce o#the wprk f�which this � . - . permitisiswed,lshatt-nofgrnploytinypersonFnony-marener � - � SItJK- - � - �rytt a - _ �.�.. : . � � � eOtl t t� - so as to t�ecQme svblect}o ihe�Workers_Campenu,n�.,Law�� - - -.. . � . �. ... ,r/� `--._. OISHWkSHER . - � . .•�,• C4NTRAC(6R- ��r_f(� � . �� j..,j� �bfe��ppiiccs� ( I����/'�.. C[O7HE5 WASHER -� ..` . _.._ ___ _ — _._ _ .- .-, -. _ _ '�CE iQ APP�tG41VT, !f, dtter making khis Certi'cate of =: .. ��`�'����� -��� --..:� . � �ption, yaa shoutd become �n6jecf to rhe 4Xarkers' �- _ : - - - - - - ,_.�,. a _ . . . .�._ r ��_ :r '`�— '- �-- --- Compensatron provtsions'af tfie Co6ar��e you must�arth-��� , �ay,�ff�pR�NKtER5Y5TEM � ��� t with comply wkth such provisiorrs ar ihis permit shol# be - STA7E �7 �t tK.�- ' . deemed revOk�d. �� - � . . WAFfft HEATER ..� .. . .�.. LIC€NSE N6.� j V �55� � . - -- - lICENSEQ CQI*('F$A�T�$5 F3ECfA[tATfON � . . - . �DISTRICF NO-.. ...PQ4CESSEQ&Y I here6y afF�rm thai 1 am ticensed u�es prcrv�s�arts of Ehapter 4_ - . ���T�M -OUTLE75�.�..- ,�. - . � - � �tammencing wlth$ection 700fF)o€Qirision 3 of ihe&usirress � p�T��p�� - - � �� E� � - - and Professions Cqde,und my ticense is in full fwce and ef€ect. 5 vER 5v5TEM . -. . . . Y . , F��`���:,� �_, va�� ar�ar� � '��'?b5�`F _; � _ � � Cicense-Numbar li�.-Clnss ..:�- :�:-. . 't . .. . � .. . . . . - FtNAI , ._� . � .. � �..� Contracea .. �� '�` .. . .-. ffy �i� . �. . � . � � � � !om exempt under Sec.. . . .. .. . .. . . . �.. � � . W .� .�B:&P.C.fw this rensan� . . . �.. � � - � .. �- � � �a» Flan checkfee :� Z � _ .-.__ ..- Qate' .._-. PLUM@IWG PERMft tSSUING PEE§ Q . . .. �. � . � . � - �. � ' � s�9�or�.e :��2 Q 5 N � . , . - . -_�. . -TOTAC FEE .. . . , . �.. . .- -. . � . . . , . . . �. - �- .- '�+.�M-•.-� .� . . - . �-- Pfan chec(��bppt�cont - � � � � � -- StNGEE FAMILY - � HOME-OWNER BUILQER DECtARATlON -- -- Nnme � ( byuff�rmthailams�cempttrau�fheContrastw'`stkcar3se _-,- ,4ddress �= -::.:-' ,. ' �-�=- ._ '--._ .. .- _ .:-� . -- "�. _�� �'�.�� _ a�� i a s� ;, .�.. C� fox-thafoFlow�ng rsaaort":j5rc3iun"�[f33_�r9us�aessand__. -' --- - -- --- ----- ------ - ___'-' .�-- . . - ---- ------ - ---� --_.. _--- Prafessianz Codaj:_ . . -. _ . . CitY � � .. TeL No. - � : . Q'�.Q ry'-"�',y�5 � � .- - ❑ t,as owner at ihe propeNy,will do the work and fhe � � - - - � - � � � . - . - str�ttu�e rs�;nat intendesl.or o[fe[ed far_saLe.(Secttoa ... -.... � - . . -. � - - t ..7044 Basmess and PraEessions Cade) . . . . .� � .� . . � � ' . . , .__ .___ .__. _- . , . ., CQI+6SIRUG710N�LENDlNG AGENCY . - _ - �- . . . . � � . . � . . . . � . .� _ [ ��' I hcreby affirm-that there is o consfrodian-tertding agency far - . . . . - � . . �. . .. . ..-.. �. .. . j � ;� the performonce nf the-work for which�this permit is issuad. - � - _ - � �� � � - . ; � - � . . ;._.. (SeC.3097,Civ.C.}.. . . . . . ... . . . . . . . .. . � . � ;� Lenderalloma �,- . � - - ... ._ . . �- . _ . : .- . � � . - . . . � - - . i � . . _ . . . � . ...._ .-. . - . - i .- � Lender's-�tldress- - .. - . - . . . . -. , . �certify tkusR i have�reod�this�oppikcQtion and state thaf the. . .� .. . � .. . . . � . above in£ormafion is correct.I ogree ta compty with alI Covnty� - . - � . .. . . �. - . . . - .. �. � ordinances artd Sta�e laws regulating Pkumbing,and.hereby - - - � � ��--.' � � � � - .. aothorize representatives af this Covnty fQ-ertter¢pon the � - �. - � _ . � � � - - � - ' - abov ienfioned propert or inspection pvrposes: _ � � - - - -- - � � -� - - . . � - . SEE REVERSEFQREXPLANASDRY LANGUAGF----- -------------------------------` � R -—-- - --- - - — - - —�- - - - - - - �.___._ .�_ .___._r_._._.___ ____._.�..�_.__�F�____,___________m___.�.__` __�___, y iqn ure of PermNfae ,-_ '.._. 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