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HomeMy WebLinkAbout1219A . �v � WORKERS'COMPENSATION DECLAR.4TION - _,jQppL1���UlV�FQt�P_.�Ul�1BtI�4.�-��P.�1tl� { f hereby 4£tirm.lha!F have A�serlificote::srl�neenf.ta self-. -7Q4667A�-��-- --- --- -- --- -� ---- ---- ---: ... . t ensure,.-or a certificare of Warkers`Compenwt�on Insurwice,��� -Ce atx(k�v,-u�e$�} --- -. _-. --�- ---. .. --- - -- - �-� or a cerf�faed c th�reaf - _- °{'r �`�°0 �':�"} COUNTY Of tp5 AIVGELES BUILDING AND SAFETY ❑cy Nc��j��.fQ�.��r�y •- . . . , . ..._�, .___ ._-.__ .,..�p.�� � ��Certificd capy rs.treteby_furai .:. _. � . .. . FOR APPEICAM TO Fllt tFf(PRINt OR TYPE} BUtLDiRIG � . �srsifted capy;a fiite�with si,e tacfrr�y�#suFFdirEg T�saec- �yueaa�z Fi�u�at�rEnn � �e aooREss - ��bon department. . . � : . �OaC' (�/fn,,� -- LOCALIFY - � - Dnte�.�jj-s.-App�iSmtlWl.FXl�(LNS- . WATER QOSE[ . . � � � .� . ���� � NEAREST r .. . � � --- CERTkFfCR7E OF EXEMFFEORt FRQM WpRKERS' . �.+ 6AiH rU8 � ^� a- eRO��T• ' �.�.. - - CQMPENSATIOh!lNSURANC€ . . - . - . . � (Th1s wttiw�nwd M�!b�[ompka3�d�Ht�a�eoh iawlvsd b�r-� SHOWER -� . OWNER ; fh�pnmk k Fos��nds•d delloes{ti46j oe 1.u.3 wvaraav uwa � { f.ceEzifythatin.s6e�Perfcrmanceaf thework'far-wt�ich th4s-�- . �..� aD0aE5S .t � S�NIC_ � . permit is�issited,t�shalt�not�empioy any persort irt any manner ' 6� � . . .�"2,i�- CI7Y 7EL,Np. � � � so-qs to 6ecome su6ject fn the Wqrkers'Cwnpensotion Laws. p�gt}yypSHfR � � - - - � � ' . � � '^� C�NTRACT6R { �- - Dnf+e��'���ArPlicant�� CLQTNESWASHER +� __ __._ . A�DRESS __ � b 'tCE-TO APPf.ICANF: if, after awking��ths Csrtificate of .. �t������ �. . : . � ,... [i :pfian, you..shoul� 6ecpme aobject to 3�re Y�!orkeri ._., -- . ... .:. „ . ,::.,� ._,_- :. :..,..�»..:, ..�2�.._ ...,,.�- __.�:��K, �. . :.. � . C.vmpensWiort prorisiarrs of tFie ta6ar£ode you rrtvit farth- . ,�. . -�..�P� - ,� `�7EE.NO.-�� - .. r,� w�ih wmpty with such provis�ons or this perm�t sholl be ������RSYSTEM � STATE - . ttC. wa��ar€R � ucgrvsE r�. cwss ;;--. deemed revoked.:. --. � .--::.- ----- . . �-_ __- _ _- . �. - � - lICENSE€)CDNFRAETO&5 DEEWRATION D45TRtC7 t�T.�e ... PR�6 6Y �_: ..•C*AS SYSiE�N --CHAXt€r5. - .. . . .: . tf+erebyaf£�mcthntlrn�ticerrossed�untFer{�rav�siarrs�Lhapiec9- � - � f� . . . g C ,-... (cartmencing with Secfian 70E1p}of€}ivision 3 0#tf�e$uainess�� - - p�7�7s py� . -. - . . ond Pro#essions Code,o�d my license�s rn fult torce and effett, � � 5 PER SYSffM - - - . . . __ ' . �' 3f����_ s�� , . �DkF� �f-E� �",� Y IDAiIOW � ;. � t,censelvum�er �ic_Gfas - - -� . --- . - .. . . . . C2 a ,., .._ . � ._ . _ .� . . :- FIN �,�- -� . - - � 6G � -; Conhactar ----�� ��-�_���� - . - �� �' . . _ . � ... __ _.-- -�---- --- . _ . ,� � 1 am exempt_u�tder See: �� . . .. ._ . . . � - . u�i .. .. _. . . . . . . . . . _. _ � . , 6.8P.C.for this reasan - - � - . � . :. Yt , 'I�aie: ___ planch_ec&,fee— -- _ __ ------ - _ --- --n c1��� `_ _ _ —_ �}r. _— ' ... . . . � . . . -.PCUM9IhtG-PERMfT IssU�NG FEE S - _ �,Q � .. _ � .. � . � �: Signatore. - - - .. . #.a.�� e �.� . F�. � ._... - SINGLE.fAMILY � . . - PMn check-oppiitart7� TOTAC FEE .� rj� - . .:. .� . ( e � �t�.ci.�S �€ "� . .H9_M€.QWNER-BUIWER.DECIARATtOL`I._.___. Name:.....- `...--- ---. ---_ __ _.:_... . . __. . . . - � 4)u..��i u - � � � by aff'�rm thaf-I om e�empt Erom ihe-Con�ractrn`s Ei€er�se � � �-- Addr€ss--_ _;_._ . - --°.. > ,_ : . ; __ _. v..-����'k�i_� .__. : t � kn Nre-kn4lowir�g reasorr�(Secliart�.7E�}#9.8usir*ess rnid �._ - ----- -- PrnfessinosCodaj�... ._ . � Ci�, - Tei.No. . . . � � � � � ❑ - � .. �� � . . . � .. � _ . ... _ - , � . €,:as owner o#the properfyr wili dv the work and the . . _ . . . � shsr�tyre As opt inisn�ed 4r offered for sale�Secfion � � � � � - - . + R}44 $us�essandRofewionsCade}. -- � - � � "� � � � _.._ ��__.___ ::. ___ _.. _ _ ___-_-___ . . . . � . � _.____ _____-_ ______. ____ �;, �--CONSiRUfT10N LEN04NG AGENCY - � �- - � . - - ' - �-- � - � � - �� _ � '�i t hereby a#ftrm tis4T there iS a cOnsirucfian'�enSiif�g ogency#or�-.. . . _.. �_ _ � . - � - ... . � - . � . � ��. Ihe per€ormonce of_the wwk for wkhitfr this permit_is-issved - - �-- �_ - --- . - �. � . - -- -- . .. . . . - '. s (Sec:'9047;Civ.'8'�. , .. ._; _ _, -" i � ----- - _, _ _----- - ---- ----- ------ _ --- � __ _ _ __-_ ___ p�. -�tender`sName--`------- ---------- -----�-------- - ---- .. . . - _._ tender's Ad6resa--- '-._ ._.._ .- . . . .. . . . . . � . � �. 1 eerti7y thuk I.l�6Ge.ead th�is.appl+'eatiad�aFed�swte t}roti the - �""��. -- �.- .' ` `= - � -- -- - --� '. �T ...._ . _ -- ..� ,__ _. . . : _.. _ ; above fnfor[rwtion is correct.1 agree td comply wi#h afl Couny � .:: ,�- -�. �:-. -. �--: �- ;. ordinantes ond Stote taws regutating Plumbing,and hereby � " .� --� .��- �� , �� �- --_ ': �- .�� wthorize rspresentahves�of ihis Connry to enter vpon the �- , - � - .; � -�� � ��� .-- � - , - �- � obore-rA hone�fsaP�nf' rnsptc�'tt+n purp6S!*s. � .._ �_ 'SF.E'REWERSE�FOH EXPli4NATORY�'�1GU/1GE ;- - .. .. of.Perinitte��.,..,_ � kSb'f�._; .- -,; _ _ . . . _ . .. . . . . _ ... . .. � . .. , , . . . . . . . : :�. . :. ... � . . .. . . .s� � . � . - . � . .. � � � ._.N.� ' . . 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