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HomeMy WebLinkAbout1228A � WORKERS'COMRENSATION DECLARATION � - �PP�t��T��IV Fi./R�P��/Y{�lIV� rENI![�1 - `� � f�hereby affirm9hat Fhave vi certificate of consent to setf 76q�7q � . . - � - � � - . insure,or a ce.tificate of Warkers'Compensation Ins�raoce, CE BP(REV.t0iet) - - . � � - - -- . or a cersrf�ed copy.ihereof(Sec,3800���C��L�� (,^Q�NTY QF EOS AFIGELES BUILDING AND SAFEiY r �� r7 . P�o4ky No�CI{1���'1 r!'.�5�.,,�Y . . . . -. _ _ ._ d�� `� . .. Cert�f�ed mpy rs here6y furrtrshed. -� - � � FOR APRICANT TO FILL tN(PRINT OR NPE} . BUTAQING - �Certrfxad.copy�s f�led with ffie couoty tiur(d«+g�nspec- � -��� � - � A6oRE55 '���(,�Q. /It/� ���.5.}� . �. tion departmewt. -- _ NUMBER FIXTURE QR ITEM � FEE � '7 �C ' . WATERCLOSET � �, lOCAttTY ��f . . pafe� O-�_. hPPI[�ant ����� NERRESt � J � - CER7IFECATE OF�E}fEMPTlON FR6AA WQRKERS' . -�L'�� 6Aiff 7UB� � . ,� ` r� CQO55 5T. cS yIy ! �� �`�L`�r(I ._ �� ' COMP€NSATIQN 4NSURANCf . - -. . . . .-.. OWhI€R rt ,� f ,� / � . � (ihissactio��aaed,rofMcomp&bd-ifthswvrkfnrcl�ad�br � �v�Ea. � . .n�-�v��ft/.- : ..` . -� . .. s cti . � tha.pgsa�If�b�Mroa�-hw�F�vddollors(fl9EF)-wioss.} . . � tavntt�ttv � � �- ao�REss��.el U�7L/ �'f+�.��� -�'�� . . -, � [certify tlwt in rhe performance of the wark for which this - - � -� . �. � .- permit"is issuad,E 3hatt noi employ ony°persan in any manner �r' ��� .. . . . �r� �`. . �Q � FEL.t�. ' " .. .. ..so.as to become svbjectto the Workers`Compensation Lows. � o�5tiwn5ttER � - - - � - � - - - � � .�y G�(� � N ,,�/Yi -- �1 CpNTftA[TOR � � Dcte r~�`a`� nrplicant Yt.I�Vdl�� � 0.0THESWASHER � � '�� ADDNfSS '� � . . -- _ "�CE 70 APPtICFtNT: !f, qfteo making.fF�is Certificate of , � ., .�� - �;.-SWit,M1kSIC�G-PAO[RE�ERfl3R " . ,�-- . -. .._ ...:. �y,T ptcan. You shoutd �come saE�jgsct fa the VJorkers' . . `_ — k -' pensaron'pravisinns of'A�e Ea6��de.You`mtiu#artk�- , ' __ ,�. ._._�_._ __ T .___ — -- _ — _�--_- =---S��k__ _ LAWN SPRINKIER$YSTEM - with [orr+piy witF�-su�h provisians ar this permit shatl 6e � � � 57qg - _ G�y . � .. deemed revaked. - � � � � WATER HERTER . � . -. LtEENSE N6. / O�V ClkSS . . - LiEENSEQ C6NTRkCT6R5 DECtARRTt6N . . DISTRICT P{O. PROCESSED BY . .. . � . . t h�re4y affirfn thnF f pm[icensed nrtder prPvks�4ns af.Chapter.-4 - �`+YSTEM OUTlETS . -- .r^• � ... � _ . . _ � (wmmencirtg with Sectinn�fIOQ}nt 6�visron 3 of the 6usiness Oct7tET50VER � �� � � . �f10 and Profesamm Cods.an�my:licsrae�rrn fsrkl FarsQ�d affast. . .5�Ett srSrErA � . _.. � .. } .. ���� _ �anr€`�L� l`l�43�` v tta�r�c�w � -�� Licer�se Number"� l�6�Y� Cic Ctass . . . . . . ._ - y�� ,r1 - FINfk . . . O.. ... C('o''n�erador �-t���/����� €3ate� � . � . .� . . . BY -.. � � . F '. I.J . � ' I am exempt under Sec. �� �++ � . . _ . _ - . . . . 0.:' .. -@.&P.C..forihes reasert - . . . . .. �- : . . . . . .. ��.__ Plan check fee � Z � - � �e PLUMBfNG PERMf7{SSUING fEE 5� O�� ._. � � .. .i�, . - . Siqr�oture .. ... . . .. -' . � . .. � �� L 2�S��i - � - . . . - _ . . _ . - TQFAC FEE . . _ . . . ,_-_, . �_ ' . . � ... - .. . � ._. .. . . . rt a • � a�� - . . . . . - � . - . � - - � � . Pfart checic applicart . . . . . . . . . . - .. _ s�nir�te Fa,nn�cr + � 1 C Q b 0 . - .--HOME OWNER-BUkLD@R DECLARATlON - - �Name�- -' . � . . . . . . . . � � � {�y off�cm thoi 4 am exempt frpm she CoNroctoc's liceme - _- - - - - " ��.e���.�. � _ � i� ror rhe�fo[1cu�ing reason:{Secrion�:7IXiT.5._Business and --= ��-..--'. - --- — � .. - -. - --- ==�'�--�-- --- _� �. .�� ,-_ .�. � � � �.. _._._.�_ ._ ..._,� _ -� - Profess�om Code):� - ,. Gity _ . . . ..�_. . FeL No. � � � � . . . . � �.1.Q 9"FS.�i � . ` - ❑. I,as owner of the property,,will do the work aid the : - - - - � � -- . - - � - - . ' ;.- shucture is not intended or offered for wle(5ettion � . . .. ._.�. .. . . � i ✓ ..:. ..7Q44,B�siness andProfessions Code}. -� .. . .. . � - . . � . . .. . � -. - : . . ... � .CONSTRUCAON-tENDING?.GENCY . ._ ..____. - . . . . . - . � . . � ... . ' s t-hereby affirm thot there is a mnstrudion lending agency#or � _ -� - �� � . - . . - _ - --. - - --� . - . � - �: ' the performance of Ihe work for whith t6is permlt is-issued _ . .. ... . . � .. � � -. . - " .. i5et.�97>Ciy.-C.}. �.. - .. � . . . . . . � . . . . ..� Lender's Nome � . � . � . . � � � .. . . �� � . . . . tender's Address . . �:_ � . � � . � � � ._ . -. . . .� � � i - I certify thot I have read ihis applicotion and state.that the - -. � �� - --,� � , . . i ahove informadon is correct.f agree to comply with a{I Counry . � . . . . � , . � � .- brdinances and State laws regulating Plumbing,ond-.heeeby - . - •: authorize represenbtires of�his Go�nty to enter upon the � - . �.-, -_- . . . _ . - -- -. a6ov -menrionedproper or inspection purposes. �E REVERSE FOR EXPLANATQRY lANGUAGE ( _.. _i�_._�,_..e.s--_,��-- _v_� � _._..�u._:..,__ _,._.._m� ��._�_.._.__.� � __ _ -- � �. - gn eofPermittee � -�Dote - . - . - . ..-.. . -� -�:�- -��-- �-� -�-- -�- �ti �. , . � � _ � o ss-� ° . �� . � a am o �a„ m ��s . ��.i�.� m@� do � a-o oN asoE p h p ;o� m o c x d . • � `p L� � . 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