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HomeMy WebLinkAbout1231A (6) (�d � WQRKEiiS'.COMPENSATION 6ECLARAFION �- - -� �pp�.00ATfON FOR F*lUMBI�tG PERhl11T - � � � I hereby affirm fhat I nave a ceAi#Fcote of conseni to se4t �pq�q�._ - � - � � iosure,w a cert�fimte of Wo�kers`Campensation Insumnce, C€au(R€v.�O��t�. - � . � ��- �- - � w a cenitied capy thereof(Sec.3soo,tob.C.} EOUNTY QF EOS ANGEt@S BU(LDING AND SAfETY P�L J�o1iCY No [ompany ��'e�'aJ6l�11/S i�0 � ��"3 rtified copy�is hereby furflished. � . � . .._ .FQF2 APPLICAIVT.�Q ftLL U+A(PRINL dR iYPE} - BUILDING � `1 __ . . � - G . , Certified copy is#iled with the counry building inspeo - ADDRE55-� �f�t ' . _�tinn deparimerti.- _ � - . . . _ . �NUhhBER . ._._FIS(TURE�2 tTEht . ... �" fEE . .- _ . . . Dafe���-�� � WAFfRCC65EF ._. ••� tL.j�pRE� � . APpfi4ant �}���.�� . .. . . . ._��CERTTFIGRTEOF-EXEhtPF�ONFR6�A W6RKER5'... .� BatHrus � . .. . � �+ c2055Sr. f. " - COM�NSATtdN INSURANCE � - - � OW�R - � � � � -� � (This��ction neod aat bo complNad�H�Jke waek iqvolved t�e . .. SH4WER -.. . the permit Es(or aee hundr�A dotlarc(S1UQ}or tost.I vivnrOftr nwtt - E certify thot in the pehwmonce of rfie wwk for which thts - � . . . � �E� � - - - - � ��petmit is issued,.I shal l nof amptoy any parson in.ony mpnner Z„� `�ryK t��� �� �� Q� � - TEL F14• � _ . so as to became subjecf ro the Workers�Compenwtioo L)aws. , �. . D�SHWASHER .. ... . . ' . . . . . . . .� .� Qate����✓ arp(icartr� IT/V��t� - �` � C40TttE5WASH€R C6NiRACt6R . . . . . _ �"'CE TQ AFPUCANT If af�eE makmg-thes Certhfmte o€ ,_... �_ SiY�[�++MtNGtlX7L&E�301� " -- ' � ^` A� - --- - — — ---. RESS prF� you stxiuid bacame sub.�ec� so th�.Wwkers` - €tFr -.._:=: �,. _T�. �[..�--.- :,. - . __ _..,__ _ _.__e ..__.�._ Compensofron provisions of fhe IoE�or�'pde you musf�wih- � kp,yyNSFRtNKtfRSYSTEM with compiy wiih svch-provisiens.or fhis permit shatf be - $7A7p� �G. . .. . �-.�deemed revOked.- . . . � � WATER HEAfER . � . ..-EICENSE N6- . CLq55 .. ��raseo caNrRacroas oEc�aaa.r�or� '! o�� �ocEssm$x , I k+erob;€affirrrs rhal i€�m iicenseEi ueulee;,rmisinr�:s,E C�pYer 4 .e'� �� ras sYstEMt.... � ouTtECS .... . � . . .:�.- . - . ... � . .. - (comrtsenang watfi Sectron?006j of Qiuision 3 of(he Business OUTtEf50YER . - - �, - -and Rrofessiens fode,and my-ikeejse-is in hr€1 forcemid ef#ect. - - 5 eEa SVSi€ta ..-.� . -. . . ` ---_.. ... - Llcersse Num6er 3����'� {it.�Class C"c��. � .. . . - . .... ..�. ���4 i'-#';J�..a�_ . YA �ATK�N- . .�. -. ... �. . - _:__ .� �'��,�,� - _. ,_._ . .-_ FfNAI � -- - . . . . -� . 6t .. Eontractor �f���-� Dafe� - - � BY E.;,._.. . .. . . d t� � �❑ I am exempl-urrder Sec. - - ..• . . . � - . . . � _ a� . . . . . .. __ . � tui+ _ . .. _ . . . . ..__ ... . . 0. - 9.&P.C.for ihis reasan - - - � - - � - - � �- y Ptart check fee � .- �. -. - . � Oate: _ . _. _ _ ' ._ . - . ... . - ..���. . . .. . .. - .. �� i��,� h -: � �. . - . ... . .- - PLUMBtNG PERMIT ISSUING F€E 5. ' . - . �SigMrture-- . � - . . . . . . . .. . 8,� . .� �`}c• a • s� . . _ 70ta1 FEE �.�R,i . . . . . � � �.� � . .. � � PEan theck opplicaN . _.. � . � . . .. � �.• ��.�Q J lJ . � � . . � - SINGLE PAMIEY . .... .. . . . . � . .. � - HOME OWNER-6UIL6ER-DECLARATI6N - � Name - � � � - � � -�- � . - �+ s�� f.1,�f'.T- - I` byaff�mrthotkamexemptframtfieCannucior'sticense - � ..- : -� .. :.:_ .LL ,-. ',,. , . .� _�--� ' -�; � l�. rarthe-Ro€towingrenson-��(Sectioa-:TtXit.5.8nsinessond -�- Address_. .:.�. -;. . _ :,, , _,:.,� ..,�-., .: . f�,^7.{,��+��.4„ �, -�, Professiom Code}:. � .. - .. . Citq . . .. 7ei.No. � . . � . . � � ._ i .. ❑- t,.as-owner-of 1fie property,wifl do ihe work and.the �-. � .- . - . . . . . . . . . � � - . j . - structure-is nof intended-or oHered fw sale(Sectian . . .. . . . . . � �. . . . . I . � � 7044,Business and Prbteaions Code). - . � � . . __ � - ." � � . � , .- j � . . . - - CONSfRUCTIDN LENDfNG AGENCY - � - - . . . �-- _ � . .._. .___.._ . _ I - . It�erebyafferm-thatihereisvcortstructiort�feerdingogerttyfor - . -� � � . � � . � � �-i . the-performance_af.ihe work for which this permit is tssued � - � � � - - ' � (Ser:304T..CiV.C-�,. .. � . _ .. . . . . . .. .. . . _ _ . I .. Lender s Nnme_... .. .. . . . . �-� .. .. . . . :-� � . _ .. _ . � � -. � 1BM�Cl1_Rddrg55- . . . � . . . . � . . . � . � � . - � . � i certify ihaF F hnve iead Fhis appticairort end stote tiral the _ �. � � . - . .�.� � � . . �- � .. .a6ove information is correct.1 ogree�to mmpiy witb all County ._- _ . . -'" . . . _ _._--- �—----. -..._--- ----.__.. -__... ardinances and Stufe inw:regulafing Viumbing,nnd here6y � - - � �- - , , - , . . . authqrize �epresentatives-of-ihis�County fo enter upon the - .--_ . � �- � . � . _. -. - . obore-rr�enr;onedp.npertp- rnapeco�orrpurposes. 5EE REYERSE FOR EXPLANATORY LRNGUAGE � �:5 V �5� -- -._. _ -- __ � S n re�of�PermittE2 � - Date � -: _ . . .. . . �-� . .. .� � _ . . . . � � � ;�__.. m'n . �..�'u� p +'_-� . . � � v "6 0 � � � � ' s a a�+" � o � n.'ci 6 � 0. m `�O �y y D � p O , '�» .0 tu+ .O � O-O d O � � � Q p �� 6i ,-C,-� . . . ,�iy;.o �°, �N mo. 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