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0750A (4)
� WORKERS'COMPENSATION E�CtARAF10N .�. � . �PP��CF°i i��1\i r�i� PEU��I�49 �Gli/Y[�T . �� i' 4 I hereby offirm �haf f hove a certifimte of consent to seff 7BA667A - - , - _ � - �t -. insuce,�or o certif�cate of Workars Compensatiort lnsuronte, CE Bt7.�REV_10/811 - . � � : -�� . . .. .� [� ar o certified copy tbe. o�15ec 3eoo C_)� E4UNTY Of LOS ANGELES BtJ41DING AND SAFETY � ts.a _� � F�o�icy N�ti�'�$�- Company . . . , . . � . . . . - Cerhfied copy is hereby furnished �� i - . FQRAPPtICANTFOFiLLiN(PRINTORFYPE}. . -BUILdtNG ... i �Certtfted eapy is filed�wiih the munty b�itciing inspec- - a0DRE5.5 . . . g - . tiondpe�pwtmenk � - NUMBER : FlXFUREORITEM ��� � FEE � ��`��� ,� _ _ i � �Date�,1`��+�APPfif,anE� . WATERClO5E7 _ � � P�AR€ST ` � ' - � CERTIFtCATE QF EXEMPfION FROM WORKERS' gAn+iue �� — ���� - � - CS�M�NSATtON thiSURANCf- . � . - . . . OWhI€R .�� � SHOWER .. -.. (S6i[�sectioa na.d awt 6.-comptQtrd�4ht mork Ferolned by .. . - . . .� . .. . ��r�fo«R.�a.�a�uan fstue>o�+�::) €,avnroar nvaa • j — aooa�ss 0 M . ��1 certify ihat in.fha Perfortnpr�ee of iha�wark far which this- .r�_ gIFYK. -. � �- . ".� C€N � �iH.NO. � - - � - permik is issued,1-shalf noF employ any person in any manner - � ���'s.�� � . - so as Eo betome svbject to the Workers`Compensation laws. � OISHWASHER - � � - - - - - _ � - . . _. CQNiRACTOR- . - . � .. �afe � A,nTnlicanf - - - � CLOTHES WRSF+ER , ` ADORE55 � � ( '!CE-�TQ NPPt1CANF: ff.-aher making.tFiis Gerti4imt�o€ . .. . . . � . . . .: . (. .nption, yt,u.;�_should 6et_oma uth�esF tp tks_WQr4ero--` � SWIMMtF1GPOOt.#tEEEPFQR ... -;__:.� _L � �� __ - _.. IEt_1tlO,:r __ _ Campensation provis�ons of the tobor Coda,yov must forth- �,q�yry���ER SYSTFM - witF comply_with such prorisions or this permie�shalt 6e SFA1E �}.�`t' LIC _. . � deemed revoked. :- � � � . - lNRTER HEAi€R - � -�-- ������ �� � �S � � . . LICENSEf�CQNFRACiQAS UECkARAiION.. - � - � � _ . _ DtSTRtCt�. . . PROCESSEQ 8Y ... ... I - -t hereby aff�m thut F nm.t+cef+sed ucider preuts�sins of Chapfer 9. . _ . GkS SV5TEM OUTLEFS —��. . . .. :._ .: _ . . . j � (commencFny�w�th Sectton 7000�af Division 3 of the Business p�yTtEfS pVER - � . _ � �� . . y. I . and Pro4essrorts�Gode,-omi my,iicensa is irr(ulk face a�ui effect-.�: �. �eER SYSTEM .. � _ HNkI� -�- � �� � �.. V l��lTl�lhl. - �` ! � O , .. � � '�, �'..�4+ . . .. . _ - -. .�, DATE.��:.-m.�,���,�'�:, .-. .. . . . ...V� ; .licerne Num6er r«��� LK.tfass . . ���.� -� -/ ��y.�- � FtNAC�--+ � � � C!C '. Centcacto7 �lL���6afe�L_� - . . . . - BY -`-`�..,.-.. . . .. . a- . V . � F am exempt under Sec. . .- �. - . . . . . . . . � � . � . _ � � _ � �-� 8:&7.C:for-thrs reasan . . -. . ... � .... . . _ �- . Ptan check fee � - -I3a)e: - . . .-_ �� - . . .. . � PtUM6fNG PERMiT ISSUtNG FE€-S � ". $ignature- . . _ . . . � . � - � .. .� , . . . ��f�.�i,�� - �. _ IQTAIfEE �U'tl - . . � � . . .� � : �� , � Ptancbetk opplican� -. .. . . � . . - . . �. : - . . -'��f s • •.� . ; . - � StNGLE FAMILY . � E �� . HOME-OWNER BUILDE&DECLABPSJON ._ Name ._ . _. _ _ ... : ..... _ + � t�Q 5 Q -_-_ g ebyaffi5mtfwtARmexemptfsoraathe:Con�racfnr'3ticanse :_.. . . --:- � ^.�:'- .'-r_ �. �;_T .�_:' ...._._� :_:�_ -- -� -_- —��.; i � U -�-i � Pow�#or-fha�iQtlowing reason�(Settfon 783t.5.Eubiness arrd -- �@�-- -- --- --- —_-— - .. ...�- --. ... � r��'��- . . � _ - �proPessFonsCode}:.-- . . . -� �. City � � Fel.No. . . � .. Q..�t,asowneroR.H+e ro . . . . . . . . � � . . � ��,�7+.�� ' p perty,wikl do the wark and the � . • - � � snudare is not inteaded or offered for sole(Seciion ,� - . . - . - � � - . . � ..- . . . � � - - � � 7044,Business und Profeuions Godej. � - . _ , � _ . � . . . --� . . :. C�NSTRUCTION tENQiNG AGENCY � � � - . . - � � - .� . . . -.. . � . - - . � . I hereby c�ffirm tFwt there is a constrocfinn lending agency for .. � . . . - - _ � .� . - � � �.� � ihe perfQrmonce of the work.for whith fhis parmit is is5ued � - - � . _____ _ � - - (Sec:3047,Civ:-�:j. , - � . � � . . . . . . . Lender's Name � � � . . . . . - . � . . . � . � � �. - � � �lender's kddress . � .. . ... .. . . � � . .. . � � . . . . . . . � . . � � 'I sertify iFid4-!hore read this applimtion and staTe tFa�the � . - -- �� -- . . � �. �. . . �� �.� a6vve information is mrrect.�I agree to comply with aU Counry � _ _.. . ._ � , . � �� . _ ordinances and State laws regulaGng PI�m6ing,ond hereby . . - - � . . � . aathorize reptesentatives of this Cquniy to e�ter upon the � � � � - . � _ -�� � � � . -- - � . � p6ove-me ioned property fo � speclion purposes. _..-. . '- - - � ' SEE REYERSE FQR EXPIANATORY LANGUAGE � �C-Ci�'3S . .- � Sig e of Permittee Date . .. . - .. .. . .. . . f .. _ _. . . . . .. _ _ . . . . . . . . � m� -� v L �v o o t� m w ' �� o-a,m o "-n a� cc, e c.pc '" ,ri u.t m o� •3 a .°a� a c � p m Q-o.o 0 °��o „�� cne`. d�n �_'c o `� °'-°o +�°'� �o cv a� ° c �'� ° m � ���- mz £� o>a � p 0 � Oi O� m g� � � C S' a c ; q� � o " , � . � 4 u � � � � A o £ `�^ E� '.�n o v °v o-o o m c °_°t, � Z ...mcv"y, o ° � a, aoc�° j� � � c ° aa'i �a �. ,. � =-b V o n _ _ . " d _ � �"Qa,,- °'"� �� ; m 3 � � a �� oi.a�iQ• ' y v e� ;;o o�� E N,`o� c m v � o y w, a... a�.c m�v ��. , ' Q-` v� T ti -' � � N tr- t 0� � y 6 u� '—,"� ,� C , 4 'w.A..:...._ � � ^'�"a m Q p Q.:�6 � n-` aq s''o p O .�.. p�+- Oi C Ol F'� . U G . . , �,.. N �� 4 � d'`lJ � m 0 0 � Q C1.y fl N� H �" C1 O Y N K D i � � . w °�3 u `- a� av� °�' a•.° y� c � � o»� ��+ . °� o n o� c o d o m°� u u °a ° � N-°o d>�i Ns ° c + , � - �� o�c d �o o °' aa c c G a� R,"-,m,.� ; £ a, p , - CY �'� � '� �^N-V v O '"'m C_ ; p •u���-� O'+� O C.a � � '�. „� `�- . . � . . � Z., o � £ �n.'-" -' o m=u� n m°° N o „ o E�� X �,j � ' � . E � m =a.oc`g m= ° �' a..'..� m��'$ >'i� °..._ a: � O Q �`"� C O'Cy.m p0'8 V,�p`.." ;p U.O'C�.O W.R V �...., 0� D � , . � p�. �'h.J L Q .,f° � p- N p��.��c,o c v ,s���n ° �Q �,ai��^ c�„C�. a�p . o , m. � . .myc7 �'�ccuo o =� ���o3 � cE c � . �� m m o m „�r. 8� .,t J m m p tr.E v w .. a � " � O Z a a 0 �i a w Z , • ,; ',,� ; "' ',, • 'c � 4` , ' 4 . O ' Z ae ,• i `'� ,n G ' � p � � ` '� � �i �� � x .. o p � ,� �l ...�. w � . . . � � ., . ' C J , ' �'� -1 . '.s . 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