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HomeMy WebLinkAbout1216A _ ��s � _ WORKER3'WMPENSATION�ECIARATION - A�P��e���Q� ��� R1.U�B�[YV PGR�iT � � t hereby affirm ehot t fiwe a certificote of content to self - -?yqyyTq .. .. . insure,or a cerfifiwte of Workers`Comp¢ngafion Insurence, _ CE 0)7(REV.�t�l81) � - � � � � . - or a terttfied copy thereo#(Sec.SS(IO,�l,�a6.�C.) . -.. .. . . . - COUNiX OF�LOS ANGEtES . .� . - BUILENNG AND SAPETY � �t" - - F�otiry No. . Campany �r'n e✓Yt4..✓1.0 : . � � : . . . --- . - � 7T._. ��:. Certified copy is here6y furnished. . � � . � � - FOR APPtiCANT TO FkLL IN(PRANT QR TYPE} � � . BUItDING - � - �/Certifiad copy is.tifed with the cpunty 6widing i�spea � . - A��RE55�� . � - tioo de rtment. � NUMBER - FfXTURE OR tTEfvS � � F6E - . �ocv.�m Date�Appli4ont . . . . �t WAlER CLOSEf . - � � NEARE51 � . . . . CER7tFlCATE QF E7CEMPTIQPf F&QM WORKERS' . ' .f�-.- BkFff 7l16.... . - . �Z ,��, CRO55 SF. � � j• � . . . � .. ��CQMPENSAftON fhE$t1RANCE . - SHD�M1(ER . - OWN€R� � � -. . ..... (Thfs secfion ae�rmt bie comptsted if t6a wa(k[maCvod by _ -�� . _tbf parrnit Is for aw�hwrdred dol{an(StBO)ar 1ws.) . . tava'Co2r- . - �~ �aE55 � �Q�� .�eL(,� . '. � t certify thoF�in the�perfArmdnce of the work fiar which this. . �y . . . . - . _ permft is issued,f shatl not employ any person f�any manner �►+ StNK ..- . � �Z �� Cttt�� - - � � t€L NQ. � . � . w ps to.become subject to the Wwkers'Compensatian Laws. . Q��,�� -� . . . .. - . ��sa � _ - ._-. �' CONFRACTOR �I ... Dale �� �+ plicant � .. CLOTtfES WASHER - .A��� _ - . . � M"'�CE,F6 APPUEAFIF: ff� aEier mdcrng��his tertjficpte cef ._ Y_ . ����� ` _ _.J ; - ___- Ption. You:shnuld become su6ject ta the�YAtarkers' -- -.L�. ..,;H . ,�„�.,n,;,,. �.�,�..-,.. ��.,..:,. ....„,.,�.:-..,� ....___..�,. :. �� pensCtioh provisions oi tfie La6or CoS{e,you rtiust Earth tAWN SPRINK4ERSYS7EM - . . . � . wtth comp{y wiih sueb provisiv+�s vr tSsis permiT shaEl be � � STATE /'� a /�f LiC, � t deemed revoked.- . . . wntER HE.4"tEn - � � �.+- ttCFNSE hK7_. J j V CtA55 - 1 �, - - - . tICEN5ED COIVTRRCF�RS DECLARATIpN - � � � I DISERICf tJ0 VROCE35ED BY � ' 1 hereby offbm thpr i om krcensed ur�der prmrsro�s of Chapter 9 .-. Ga5 SYSt[-t.5 � aurtEiS- •►' -� �C�. . - . . (commencing with Sectron Tp06j of Divrsinn 3 of the Business WttET50V€R - - _� qnd Frofessros+s Code,Qrtd rr�y ticense Fs in#ufl force a�d..effect � 5 vER SrS�M � �' .. � 6A�€- V�1 (DR'FIOW O _ � licanse Numbe���� Lic Ctnss� ... .. .. .. � ... .. � � . �V . . t - - FINAL . � Eontracro . €Mte �'� � . . . . BY - _ � . . 0 �' ❑ I am exempt under c. - � . �.. . � � . � � . . - . .. . tti � - . B.&P.0 for�this reasan � . . - . � . � � � Plan check fee _ ? E _ . . Dnfe ... ... PLUM9ING PERMlF 4SS11lNG fEE S . . - � �� . . . . . . �� . � .. • . . Sigrtaturn- �. . . _ . . . - � - � . _ � TQiAI FEE � . . CQ. _ _. . .-_ � . -.c�I ��.Er A .. . . . . .. . ._ . _ . . � Ptan cfieck appiicanf_. � . . - .. . .. �. . - . . . . � � -� �e r r � r 5. . . � - - - StN6LE FAMILY - � _...__. . _.- - . � � � � -- . . NOMf OWNER-BUIIDER DECIARRTI6N � Name - ' _.j ��S_� l�t �by pHirrrr eFaf i om eicempt trom3he Gontrpctof's lFtense . . .. -- _ , ,Y� - c - Y iV+,Y ` .. .. L ror the f4kfowkng-reason{Sectiaf-�7tt3t:5r�Bus#rFeas ar� A�4S�5,:;_: . -.�_��:::-�, �e`a ,�. _�. _.:;��� ��.,F;:»� ��._..,.-�;�..,..�.ar» � �_;_, va -��_ � .�:.e_„. . 1��JUcs � Professiarss Code�-- - - . GFh! . . . Tel.No. � � . �. . . � ❑ .�.I._as a5rr�ec_af the-pmpertyr witl da the work and the . . . . . . .� . .-. - . ... . Q�.��`�� - � ` _-__�structure is_not in�ended or offered fw sale (Section - � _ . - . . - - � . - � .. - . . � 7044,Business aod Prnfessians Code)., ��---� � . ... � � . .... . . ` --`--LQA15T�[iGItC?C�l�c�AGFFgGY. .. I herek�Y aff�rrrt-thet there-is q mn�truct�on�lend�rig�oge�cy for .:.. ..... .-. � -� � - � - � - � - - � ;_ � 'the p¢rformance of the wwk{m wMich this permit is issued - - . . . �- � � . . � �� ($ec.�9047..Civ.Gk. . _ ..:.� - . . �� - � .: . - . .. - � _ . . . . � . . � . . - .. - . � . . -� . � - � ' ._ Lender's�Name ._ ._... . . �� . . - _. . . .. � .. - � � - - - j . Lender's.Addreu . . . . . . . ..... ' . _�_ ... � � - . _ � � f certify-that t have read�this app4Em�ion ood state Niat the- . - � - �__ � - - � . � . � '�. a6ove informatinn is correct_t agree to comply witfi a{I Cnunry - - � � . - � - - - � � . - � � ordinpnces and Stote laws regula�ing Plumbi�g,and hereby - . - . ..� . . � .. aWhotize-representatives of this�Counry 7o enter upon the � -- . . .� . `��-� � - - � . � ��: - �ahove-mentionedpiopar�r-inspecfion purposes. . - �. �� .-. -. .. . . : . ' � ��� SEE REVERSE fOR EXPtANATQRY LANGUAGE � . I . 5 n (�rb of Permittee . .. 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