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1201A 1202A
�' . WQRKERS'.C4MPENSATIONDECLARATfON . ._ „ _ �,�P�,ICi`4TIVLV �QR ��UEY�BI��Y PGR�iT -- � `� � � � [hereby aff+rm thaf.F ha+re-e centtkcte af�consertf io seff� J6Ayy�q : . . � - j ins�re,or o certifimte o{VJorkers'Compenwtian tnwrance, CE 817(REV.t0i8t} � � � - . � - - � - . � or a certifiect copy ik�ereo€{Sec: ������� COUNTY OF lOS ANGElES 8tlILDING AND SAFETY ��- ,j Z � .__ PQolicy No.- Company . . �-- . . . . T - ( Cerfified copy�rs�f�ece6y furnished.-. 8UI161,NG � - . - j FOR APPLKANT TO FfLL IN(PR{NT OR NPE) pppRE55 ��� � (f , . �ertifted capy�4s#iied with the counry bu4lding inspec- .. - . - .. fion-depnrimen4. • �� I NUMBER FIXTtIREQRITfM -(� - FEE `�`�TM . � �.� Dnte�1t�ARPfi4nnt � • �. �. 'Z.. WAFERQOSE7 - - `�},, ^� . . � _ .. NE/kRES7 4 R �� .- � CERTIFtCATE 4F EXEMPTtON FRdM WORKERS' .. . Bn7w�Us . . . � �'},,.. � eR��T. �`�' u� �� . - . �C�MPEN5AT16N INSk1RANCE -� - ��R . . - DWNER �- ,Q � . . . �. . � . (T�is secHo�naed aat 1»sompteted�Mu�rork t�rolved by . - . ..�.� � � Ike pwmet is for ane hundred dollnn(5100)or lesc.j twvatOttv t'�f "' nD6RESS � Yt �fd� � E certify cReft in the performance of rhe work for whtch Ehis .. . - . � - . . , t � perrnit ks issued,.l shall rwf empfoy any persan in ony manner �� SINK � � C�TY � �� .���_ ZEt.NO. � - � - - � � . so as to bccome subjeci ro tbe Workers'Campensation Laws. , 04SHWRSHER � � �y. �+ - - - �ffy��!+1�fn�Jf CONTRACTOR �e potK����nppticont[ +r ic.-��� �� CIOTHESWRSHER +.r . .. . - -.� �TICE TO APPlIG4NT: If, atter maki�g�this Cerrrficate at -- - - - -- -�� _ _- V =- - pfien, ya�.-:shoutd become su6ject ta the-:Workers S'A'tNUNiNf+.P40€RKEFEQ4 __ _�=.-.� ..�pensatFortprovisiansof'tRs'ta6or£oda,-pvv musf�foAh- �:� --. := '!�"p��:��- �-.�;� - with coYnpfy with such provisioni or-this perersil shpll bt � �WNSPRINKL€RSYSTEM SIAIE '^2 - LIC. . deemed eevakec��� � � •� WAtER tffATER � � KEIJSE N6t,�� ' Q CVi55 � � --�- LtCEN$EQ Cf}MTRRCTORS DECtARATtON . . -- -- - OISTRICT Np. � -- PRQCE$$ED 6Y . - t hereby c�Efarm fhat i am l�renxd urFder prqv�s�Or�s Qf CkwPter 4 � GASSYSiEht -�Ot17�EfS. : � �. ' /� .. ;- . . ... � . (camn�encfng with Settwrt 7WU}of Qivisian 3 of the Business... - pUhEiSpyEtt . �� - . �� _ ond Pro4ess�ons CodeE and my I_ice�se as in fuI}force and effed_ - 5 PER SYSTEM � - � '-- �"-.�� �y{ F�wti , n {tAlIDATK?N �' � license N Ym6JeY�/ ��-� tic.Class � . .:. .... . .-. . ..:-. .. - DA.TE :��'�=�;`�� .. . . . _U . . - :(Y{ � . . �-� y� �1 - . . . � FI � � -0 - ContmcroF � .. Date�� . . . - - . BY � ... . � u a_.t.om ezempt.vnder ec. . , . . . . . -- . - . _ . � - - � � . � e.aa.C.fw rhts reosan Plan chec&€ee � � z o�re: �uMsfr.�aHzna�r tssu�r�F�e �1 2 Q 1 R -Signature � . �'4 �a . . � .. � . j �. � . . �._ .. . ... . . 7QFAL F€E . �� o �-�.s s,� � � : � - . . . -. . . . - - Rfan check app�imnt- . . - . . -.. . � . . � . -.F.�-•Ll�x rJ 0 - t - � SINGLE FAMILY � � q - H4ME OWNER-BUIL�ER 6ECLARATION ' Name •• •(j(�,,F,G� f i�` �6yaHirmtha4JameaemptfrwnaheGortfractnr'ati€eaae � - .,- - �. , .. , . ,.. . ... ._..'� .r _ ' .� _.� ( Address: , . , .;_ ,z x ., . ,.. i .. �L#�. ;orihefokt+owingreawn:-j5e.cttonZflS}.S,Susic�€assand -� . . . -�.��.�- :: � . - �,-� � �-�(}��£��' �-._-��1 - - � (P�ro'[fessions Code�;, (�j� 7e4.No. �1�af G� � � - L�[ �t,as owner of she property,wiil.da the work ond the � � . - - . . � -� sJructure is not intended or offered for wfe (Sectian- - . � �-.-� . � ���� ��_� .r�� 7044,-8usiness and Protessians Code) . . .. . . . . � .. . . � CONSTRUCTI6N LERIDfNG AGENCY . -� �� - � �. . . --- r�� '�C�D O - � ' I beFe6y affirm iha�ihere cs ci coristructian iendtng agency for . � . � - - �-. � � � � � � - �� the perf�mnnce.af the.work#or which ihis permit is issued � _ � •,' •���,C��� . - (Sec.3047.Gv C) 07.(?9yfs5 .. � Lender's Pfame- . . . � . - - . .. . � .. .... . . .._ . .. - ... . . lender's Address . . . --.... . - - . . � . .: .. . . . . . . 1 cedify tfiot t fidve read fhis appiication and stote thot the - . . - � - . - - - � - � . � . -- _ � . above information is correct 1 agree to compiy with aft County � . - . � � � - - ordinances ond State.taw5 regulatipg Pl�mbing,and hereby . - - � . ' - authorize represeMotives of this Co�nty to enter upon the -, . :� - � � . . � � . � - a6ave-me�stioned p�operty inspeUion purposes. -� � . .. � - �''1 ,�J � SEE REYERSE FOR EXPLANATQRY IANGUAGE ' /�'e7"�Q �_ . . . _. . . . . .. ._ Si a�r of Permiltee �. pcire . . -- -.. . . . - .- . .. � . �., d-� ;, +�g °�-� ,' � , � e � NN o� m o �a„ �� os „ �: , , a� _ �'� � a�y , � a o y .. � ,,;�s :'. �' = ;os " ot -'r . cio �3d� .-, � `�.ML..� N'in N e7,� �� �L .,.� �S 0 O C�m ��� � . . ,�� O un y� O�8t � u�-p O w � �,�p 1- �-� d"' Ov p °n " - . ('' 61 C, O � n � �• . . n ���i y i. � . C G f>� .41•O�n Qi p � m � O w 61 � O � � p'�. . ' . i.,...,. V ° � > a� o ° £ �, E .na 'o � � cam yo � $ . 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