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HomeMy WebLinkAbout0763A -_--�- WORK€RS'COMPEM1tSAFtON bEetARATfON�- . p9PPLiC�4T10M Ft�l� PlUM�IIdG-PEltM1T - �-�� � j 1 hereby afF�rm thnt 1 have.a certiiicate ot consenr to self Iy��q.. . . - _ . . .. __. � - ins�re,.o�a cernficate nf workers'Cam�et,sariQn Ins�ronce,_. cE et�(R�r.�aiat{ . � I or a cernfied copr�hereof{Sec.3904:iob�C.# ___ CQUNTY AF 1Q5 RNGELES _ BU1lDM1G AND SAFETY_ Poficy�Ne. �.- Eompany . . _�. ___ __�_- __-- ---- - __._ .___ ._._: � _. _ ��� Certified capy is hereby#urrt�shed. ;_ , Foa,��ro Fiu ir��reiNr ox rrae� auaoErv� t �Certified copy 3s�'iledwHh tfie cnu�ty ttratid��crsp�€- - �. . _ � A6QRESS �-�-_ -- - .. �- t�on departrnertt _ �_� , ` . N[tINBEK�- FfMtlRE-QRftERR -: � .-_.-}� ___ _.__ ___`�� . __: _ __. •- t LOCAtfTY � Y . t UakelCC�-APP�FSPn# . •. `: �/.- WATER CLQSET . . ... ...._ � �..._. �..__. � _ � .: . . .._ .�_,._ . _ __ . _._.._. � _..._. -r -� -� — - fBOSS SS � ! -�xrrFtca;�aF�r�v�u��aer�rvor�c�rt5'_ �� $ar,+�- /1 p� . -- ccxnrf€n�sar�}t�sv�� ~- - = _ --:. _. � OWNER (Tbh sQetia�►naad ae►6Q iampla�#�a worlc�b�r �H�wE�z _ ' nAn�t � _` ', � eh.pecmir�s Esr orw bwr�r�d�IQrs(�t�},or�:l _ �,,.�- uvauacK- 02� nfi?oRESs . �3 - - . -- � . � 1 certiiy thtrt rc%he j��armv�e al��italrfat-�;dz fh i '.: t . �. - .� {�cmi1 is issued:t shat�nat e�r+Plgy�ss�ycPe�u+cu*v:Eru+nnar. -. � .... sfw€_ , ���. _ - -�-_�tTY ��?'tlw.t+.... - Ift.tyQ.=: . .-. j �- sn as tg besome se�ect to the�orkexs Cam�zqnsffi€ffn taws� � ._f?tStfNtASH€R�- .. . .� '- --� �_ -- - - - - - - - ` f -- =-::' �• .�:� _;:� _.:'_� _�. ,.. _.. . .C�PiRRC[Ql� �.�.. . _ - _. . _ -- . - ___ .. . .._ _ _ __ . _ ...: . ._ - _ _. '-._ .- --.---_..4 «. . �� _.' A,�,urElCQtif =___ -_ ____. __�- _�__ __ - � _ -.__._. �. . ._ - _ __- _-- _ � ,. _, _ . .. -: � _ Etp.FHESWt3HER -_.� (j��:.ADQRE55 :. ' ,_ � T10E TC}APPllCANT: [f,after making r�is�ertificate of $�������� _ . . ! nption. Yau-a[so�rfd becsame �ub�ett�o the Yt�arkars' , �:.: . ,._ � . . Ccmpensatiort�prov'rsians of tl�r Labar Go�.Yov mast 4aHh � LAWN SPRENKIER SYSTEM �.. � ��t5' . TF1 All}.'" ! with cbmp7y with Such provisior�s or this permit shall be - �� STAiE �- n �-+�' � tK. � � - , deemCd re�rOk6l3. . �- �� . WATERt1EATER . . ..py� . LKEN�NO:� i �'C�J C1q`,�,5 i -�- EICENSEQ COP1'FRRCTORS DECtARATIqN -... o�57aic7 ta0 FkO�55Eo BY p #herekry afferm tkwt f am 6eensed une#er prov+s�anf s�€fhaptef 4 __. � - GAS SYStEnr . OUIlETS.. .-. . . ��l..- _ . � jcoavn,er{ciag eeith Secilan 7IX1Rj of Qisresinn 9�f�6e.9isiness OttTtETS OVER - } _. � mp licec�se'ra in EuN forca fu�s3 effest. . - s�&svsrEnn �� . . -_ .. ' e� � andPcafessions�n�d� h � DRtE ti� _� . e=:�;� YA AT[ON _ �- E'ecense Number ��� � tic.Cfass�'� ���� . . " .' . � _.. . -. _ . _ _ .�. `•-�"� � .� FlN.4f. � � . � .. a ( e-� "_ _ '__ .Canhactar_ {}nte t �-- . .. . . .. - . BY �--_���.� . ..,:_ . �. . ❑_.. . . _ .. - . . :- .... . . .. � . . .. . . . . . .._ V � . 4 am exempt under Sec. " �++ ' . . . . ._ . . .. . _ 9. ' � .....B.&P.E.far this reason � . - . . .. � . - � i Ptnn c€�eck fee _ Z . .... . . . . . � � tlaie: .... .�. �PLUMBING PERAkfT f55UING fEE S . O. � .. . .. .. .. �z��.�t u-.�{. . � E - . Signature .. . . . . _ . ... .. � . . . . . . . -. � . . . _ . � . -- TQTALffE . - �p . - . . �,e-. e • s� � . _ - � PIQn check appticant � � . ��• a��X Jr t3 - SINGkF FAM1hILY _.� HOM€OWFtfR-BUkL4ER DECtAf'ATtON - Name - _ i 4 ��i,-3}r '�`? r-. �6Y affirm thapi um exempt ftam the Cnrkqctsu���Licanse. � -_- - �, - -- ..� �w�ar tfie fotfowing reaso¢jSettion 7�T 5.Eusiness hncl �4�.�- . __ - ��_ ` ` . ' ���� �"c�i� „ 7 , �_.. {P�aafeu'ror>s Cede}:_- _. _ . ... . �ty . . . . TeI.Na _ - . . .. _ , __ _ . � Ll F.-ns o�r�rsr.o�the P�s�per+Y..vzitl da the*w�.€md the -- --- �. ,. stru�re.zsnorintendedaraffgre�farsate-j5ectfarr --- -- --- .__-_ __ -. -�.. .. . � 7044,Busioess and Professions Code}. '- . . � � -�-�.. - � � -� �. �. .. � � ..-- .. . . � j _..._. :_ CON$TRkKTION_LENDINf_.AGENCY_____ . .-- � � . .. . . . . - - � . ._._._ ___..__ ___._ _____..._._ . _...._.____ ________ __.---- �- t f+ereby off'am-tfion�er�'rsa-rnc�structiarx�tenrFing�ageney#w-� - . -. . . - - ... . � . . . . `-°�- the.perfwmance-of�the v:ork.fw which rhis�-permir is-'+ssued.- . . . . - � . . - �� . . . _`_. . '� -� (Scc�9Q47,LiyeL.-j� ----------. : . . .._ . � � � � � _ -:,� - ,-. � ---'- --- --._ _.-_____ __--------� . ._ .. . Lender's hlame �- . . . . . . . . . � . .. -6 � Lender`i Addre;s_ .. .-. _. - . - .. . .. . _�. _ - . - �..�__. .�. - � . _ .. .� � i certify that f twve read itus.npptimtiQa and s�ote that the � :� � �- -�. �1 abave-infwmethon+sc�secE I�grree�sct�mply witbettCounty--._ .... .... .. ..._. _.. . ----- -�-- -. .. ._ ... .. . . . . . . . . j � nrd`rnances ond 3tote-(aues.regvlWmg.ptiem6eng..aric��:�ierebX��:: _. . . . . � . . � , - - ... � cuthoriie represeqtatFves-af�lh�s Cwinry!o enter_�pon the�--.. _.. . � - ______ - . . _ � - � � -� . ' . . ._.._._. . - `---- ` - aboae.me tkoned.property fac spectionpurposes.:.:` --.. � . ._._._ � - _ � _. .. �- � . . j - 5EE REYEBSE FOR EXPLANATQRY LANGUAGE ; - _ . 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