HomeMy WebLinkAbout1204A (6) - �. WORKERS'COMPENSATION DECLARAFION - APP![CATt01o1 IFOFt PtUMBING RERMIT �`�S .. 1 here6y affirm thvz.t�.Moue a cestificote of consent�o sel# 76n667a � . -�- '. �. . irssure,w a certl4imte of Workers'Compensation Insurance, CE BIZ�REV.tOFe�} � � - � - . . � �� or a cerufied copy rfiereo€-(Sec:3806,lub.C.E COUNTY QF LOS ANGEIFS BUILDIN G A N D S A F E T Y Y 1 � � .. . . POaticy No. pany . . . . __... ____ . . d�a_� Z .. - . nified copy is hereby furni d: ' - - fORAPPI.ICAM�TOFlLEW(PRINTORP/PEj � @UlLQING � � Certified copy�is fited w4th ihe€oan 6vilding inspec- ADORE55 - � tion deparimertt. . . . : . . NUMBER � FIXTliRE OR tTEM �� � f� ----- -.--.. .: ��. : Qate.�.:S��� WATER ClQSET - ` EOCAL4TY � . AppdiGant t NEAREST - -. � � � CERTlF1CATE QF fXEMPTION FROM WORKERS' . � BATH 7UB . � . t - �„ Crz05S 5T._. � � � COMPENSRTlON ENSURANCE - - Owt�R - .- (This s�etime naed iwt bs completod�Nw-�rcnrk�inrotvad by SNQwEa - . - . - rc : � IFto paemit Is for ana hundred dallun(S1UQ}or leu,t LpVaFOar � � � _.,. q�E�_ Q . I certFfy thaf in the pertormarzce of the work fa which�his . - - �, permit is issued,I aFqlf not employ.any pe�son in orty manrter ��NK - ptt . - T€L Np. . �. so as to become sub{ect to.the Workers'�Compansation Laws. DISHwASHER � - - _j ` [ONSRACTOR�. - nQre '?-S -�S aT,��can� 14t1/��fE' c�on+esw<,sr+ER � �"�� - N'"`('.F�TO APPI.{C/�+kT�_If�:n#e�.-rt+aki�.�is�_€.e�tifitate o# �-�.- � .--. .__ MQft�S _ . _:_:. .--_ __` _,.- .� E� �tian y�o ifwuId-6eiaine wbjeSx W Ehe 4AEorkevs' -. . _.-.Sw�taLtttraG�74CH€CEP70R �.--�. - - - - -- -- � " ` . _`-_-- ,__. _" -- - - - -� ;- _ .. _ _: Cou�peresatiort provisions af the La6or Cocfe,you must forih- - �- � TEl_NQ. - � LAN"N SPRIFiKLER SYSiFM � � _ with compiy�with such provisians�or this.permi�thQ[I 6e STRiE � -� - _ U�,- _- de4mCdra�oked.- . . . . WAFERF�A7ER-. ., . . . � . �f= - �r IICENSENO.� .:��p,�- . . �.: LtCEP15ED CONTRACTORS DECtARATfON . � �� � - oaia�cr ax3._:_. �.: raocEsseo ar - � � . I hereby nfftrm�hot i am Ircensed urider prov�srorts of Chapter 9 . -GASSYSiEM -� Ot1RE€5 - . . . �.. . � � � (commenci�witEr�ct�r�Q44k c€QueuiEm 3 taf thc-a.n:.,�.<e �-. . �. . - .. f)€)TtETS E}YER � and Protessrons Cpde,ar�my fKense is in fu�l fcrrce a�d ef#ect. . ��R��`�h� � � ��- flNAL -� ��- - � , � License�:Numher.'�{�j�3� ��tic.Cfass �"� .. � ...:_.. ..�` .._.. .`_ - S��.-. ' ' ... VI�lL AT(QH _ .. . �' {►� �AF€ i, �r�t.. ,_".._'W` () . . � � . - . - . U § � . . .. - � ...._.. . . . y�-- . ftNAL _ . . . . . . � �. Cantrru�w Date ��4.1�. � � ... . - � gy - � �-� � � Q� � � � I am .�pt under-Sec. - . -.. . . . . . . . . .. - � � _ 8.&P.f.far this reoson . . .. . .. ��������i� v�'i Plan check fee � � : �,�: : a �.. ...� � 9 auMSEcu�e��nnrr ossu�ntc�s f . .8€?:5 G � - -Si nature . . .. .. .. . . .. � . . . . . � TOTAk EEE .. . � . . .. _ .. . . . . . .. . . ► �e�t�.-�'j(J�... - . . . � _ � Pfan c6eck-appficant . . . . sEr��Ee Fnnni�r a 7:0 9-8 5 - .HOME OWNER.BUktDEH DECtARA740N -�� Name-- - � � � �- - - - � I� Sy affirm that f om exempt from the Confractor's License _-. ��E��_._, - �. ,- _ ___,, - ` ;.: . .. � _:.. .•:. .:.,. _. �.. ..... € .or#�e faflavsi.�g revaorr�(Sectton 7631.5,Ecrsiness bnd . � � -. . . - .. - Professions Codej:.� ,.. ._ _. .. . . � CitY � � Tei.Na. . . . .� . . a �' �� -I;as ow�er o#the properry,wilk do tba work ond the � - � �- . - -� �- � - � � � � . � � ..- t !� .- sh6crure is not inteaded or ofEered for�sale(Sect�on � . � . � . . . . �. . . - .. _.. . t --�7044.Business and Professions Code). - }. ... - . . - . . . � - - . . . . . � � . . . . � . . __ . _ _ . . � - CONSTRUCiION lENQWG AGENCY ._.., . � . � � . - .- � - � � - - ---- - E�hereby Offivm thaf;here es a consiruciion tending agexy for . � - _ � : - - - . � . - - � fhe perEoc�ce�of the work for which this�permit�is-+uued _ � .. � - . � . - ... . . . .. . ... . � . {Sec:3�97,C�v.C.). . . . . . .. . . . Lender's Name �.. . Cendels Rddress . . . . . . . . . . . . -..� .. . . .. . . - .i certify tttat l have reod this applicofion and s�a�e thm the � - - . . �- . . . . �- �� : - abnve information�is corcect.I agree io�compfy wi�h afi County - � _ � - �� -- - � . ardinbnces and State faws regulating Pfumbinq,ond hereby - � � � . . - - � aurhorize represeniafives of this County te emer upon rhe' . � � �� - � � �- - - - � . � abov -mentbned proper�y ' speclion purposes. - � - . - .. � . � SFE REYERSE P�R EXPLANATORY lAA1GUAGE _ _ - — ------- ----- ---— ---------— __- _ - -- _ _-- - `-�J ------- ----- -----------— � � ign re o ermittee � Date � � - - � - � � � � � � . . �°�. a�-� ooc-�-o H c =-o c o m N c a'" � . y'L `^ O Q�. O . p. 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