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HomeMy WebLinkAbout1220A (6) _ WORKERS'COMPENSqT{ON DKtARAT10N - � �. -- . �PP��CAT�ON FQR r�UMBI�� PERIY,IT `s � ' � I hereby a�ffirm.thai!have a-_certificate of consent�o self Fbq�y�q � - - � - � - insule,ar a certificd�e of Wbrkars`C6mpensatian Inwrnnce, CE g17(REY_10i81j � � � - - - - . � . .. - . or q certifiebd�c1o,�1py thereof(Sec 3&l0,tab.G} I,f CpUNTY QF tOS ANGElES BU{lD4NG AN8 SAFETY � --} �\(� � P�olity No/�(✓!��i.��,�pany—���L�l��'1-�!(C1 - : . ��. � � .. . � _ . � �.: . . . _ V W J�'�O. .. rtifted copy is here6y furnished. .. _ _. . .. �FOR APPIiCAMT TO FtLt IN(PPINT OR TYPE) BULLE)ING��,j� `Q� �/� / .- �rti{�ed copy is filed with the coortty 6uTding-inspec- - � - . ADD�SS / iC.. i�i cc..� . . tipn c(gpprtm(s��n�t-. .. NUMBER FiXFURE OR ITEM -�,b FEE ����tt � � DWe f-`�:GJ qPPfitanf �l�/✓� .�'L� . ..: . WATER Cl65Et ♦�y �- NEAREST -' J� �` . &ATFI TItB - � . . � �+ CROSS ST. - - � CERTIfiCATE OE€XEMPTION�ROM WORKERS' Z- . � � - -- COMPENSAttOf11N5LERANCE .� � . . OWNER � � . . � (T6tt agctian er�ed aat 6e camgfafe�if#ke rrork imra[red bY�.. SFIaWfR � . . . - .. � . � MAIt // �/ . . }I1��F[o't1ifEorO¢lhYRd(Yddallafs(�E@Fk}aFlBss.� €AUATORY � J AD�RE55 /C. C�/ - 1 tectifY that-irs the�rfermance-o4 tha�-varnk forwhich this�... � . - .. . . . . . � permit is'xssued,t.sha{t.na4emplayaaY-F+ersoninc�ay�manner. ':Z.� StNK. . . . .. -�� _ OTY i€l.NO. - . . so aa to��became�subjecl 4o the Workers'�fompensWio�r laws. QlStiwASHER . . . . r^"' . . _ «� q/rt �p CQNFRP.CTOR, - � °. �: 6ute f"�'� ArRlicnM /��"`V�O� CLO7HESWASHER . . � - - . - . _ . . �CE.-TQ APPLlCANF� kf, after mak�ng�thrs Certrfimte of . ADDR€SS S"' ,�- � ,ptian. Yat�:�vls�.4ec_om� s�b�ecf ka fhe.SAlorkers' . �." SWtMMChKiP06LkEtFPTOR : ..:.. , .. -. _ ... .. � ._ .,: -- .- �__. . -- ' '-.�,� ��:.` -�- -,_,.,-_ .�'. iEE,�lf�=�- -�-. .�. �urnpenwtian prbv�sinns o�fifie Efl6or Code.Yo�mnai#oNh-' .:: tAwN�RINKkfR SYSFEM -_. _ . ,"c'.-." .. -� =. --�.- _ with comply with such provisions or zhis {xermit shall be - S7ATE - �^p , - tiC. � - - � � deemed revoked. . .. - . .- . . WAFER HEATER - - r� U�NSE NO �/ . CtA55 . .. tICEPiSED CQNTRACTQRS DECLARATFqN . � � . � DtSTRICT N6. � PRaE55ED BY - � � t hgeby aff�rm that3 Wrz 1lcenssd ur[der.p.ovisions a€,(�Pf�c.9 . . 6PS SYSTEAa Ouri€r5 . .�. . ��.�_ .. - .. ... . .. ..� {eommertciny.�rith.Sacteon70(1Qj nf Divis7on 3 of the 6usiness � OIlTtETSOVER , . � . �. , - y and ProfeuisrrEs Ga�e,undmy 4icen�iz in lull#acce andefEect. ._ _ 5 PFR SYSTEM __.. - FkNAt - . . .... �����.r� �`,�,�'�/ �are ' ...,-� Y IIDFtTIQN � ::f Gcense�Nvmber• , !'rc.Class� __ ..- ;.. ,�.-..� ."= - ..... . � ���� �� /Q�/ �['� - PINAL .. . � . -. Q 5 . Canfractor �{��'4f f�-J I1ate -`-� � � . . . . 6Y � _ ..�. . . � s,,, � . �� I am�exempt urtder Sec . . . - � _ . . _ . . . ._ . .. � . V d . 6:$P:C.for this reason - � . . . . . - . . - . .. . .`. . �� � � Plan check fee � _ � - , . . . [k�te: , ., . . --.PLUMBtNG PERMIT ISStrING FEE:3 - . !Q .. - ' �- � SigrwFur .. . . ,�!.., . . - . . � . ..-- � �� . - . . ._ .. -� � - TOtAI.FEE �. �. �1 . - . . � . - - � ... - . ' Pb�cn��aPa�,�a�r _ �1 2 2:0 A : SINC'lE FAMILY � . - . . - . . . � HOME OWNER-BUILDER DECLARATlON - - Noma . . - - . - .. � � �.s�'• ` '� .. I�� -by affirm thot I tam exempt Erom the Contrac�ols ticense ��. `�� `���;, Ct ror tfie#otEowir�g reasoTi��(Sacliari TU3S.5,'Btisiraess and -- ���'u .:' -- '" ,.. - .. y- , --�-$��.t-L�.r-,-U�-x� ..V.:� ... _ . _ .... _..�_.._., �,s �. ., ._ , .. Protessions Codej: . fity TeF.No. . �a � ��y.�v� _ � � ❑ t,as owner-of the propeolY,-witt do the work and the �. - . . . - . . � . � . . , �� . . ._..struciure is no�Intended o�offered tor.sole(Section � . .. . . � .- . .� � - . . . - . . .Q�,��i-�� .. - -� 7644,Busineu and Professions Code}. � . ' - � . � _ . . . . --- � - ` GONSTRUCTt6N lEND4NG AGENCY � � � - - - � � � - - � - - � � . � -. �. .� . .. . 1 here6y affrcm that there'rs a�consir�ctiws�ending�dgei�cy#oo-- - . � � � --� . . . . . -.� - . - � - - � . . - _ -� the,petfarmanceaf the work for-whieh-rhis permit is iswed �_ - � . . . _ � . . . � - - (Sec 3047.C'rv.-C..}.. - - . . . .. . . . - � � . . . _ .... lender's Name � " . . �. - . - ..� . . � � . . . � � lar'der's-Address.._ ..:._ _ ..._.. � � � � . . :. -� � � . . - . '' t certify�Fwt i have read this opplication and sfate That the - � - � ' -_.- obore:information:is canec�._k ggree to mmply with ai!Covnty - :. . . - . . ...- .. . � ..... .... . . . . i ordinancesqnd5tak�Ia.m.r�4ulqtiqqPl4mbing,and__here6x.. -" . - � � . � . �� ' authorize representabves:.sE.�this[nunty.tcE Ea3er:-upert the..:.;.. - . . . � . . � . . . . . .. � f -- obove-menftorred-proper ='_iinspedion.purposes.._._; .�:'-- --.-. - . . - . . - - SEE REYERSE FAR EXPtANATORY LANGUAGE � .__ _ - -- _ ___ _ _ _ _- -- . — -- ------- ------ , � �g ture o ermiflee . - Uafe ` -�� . :— ... — — . .— - -- — _ _ -- . � _ _ . - ._ -_ -_ __ -. -- _ - _ -_ _, '__-� ,�, n .. ;. m—� — _ '. � � .y V u .�.."t O O,G... . , ...... ti` . m c 'a � 'o r`''� N m °' °�'� ��n o a m ° 'r'a'0 m �e.c `a4 ; ° N � OCamv�'im� o' aoh �d� , 4+ • �� �m °mc �.a'c � 3 ' m ovc.Aa � �:1; '' . � .� O.'� �� �6i w m�d C ��� ����' G �.w O p,b . � �. . � `ti L O W u -� o � � h `> E v, ° o a c'3 a ., a � O - .c n o ° .°� o a o c o o-° ° v�°v ov o m o a,o �_- "'"�a_: o:..�,�`- oN� =-o � � � ao �od U a o « E c � E �.t P m y ' -- m 3 �'c + E o �'.°'o o � � °' P- � � Q O C m � W m �- G fil � � O�w�� �i �� 5 � ' � W � �¢ ° � mooi °.Q �o oomam „- o''° m � •xcro;; oa�-�oy � ° e Q-aoo� o °' ��F u; c w a3 � � nv �ur, xop.._ ��a`, a �,� N� � � h � ' E� " cm �vod " E� �.' s �c '�^ >mv�°- 3o� m � °.° � o om-, , mm °� oc'oaQ�u.�"�.c � -v y � ou �... 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