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HomeMy WebLinkAbout1226A � . i.�s WORKERS'COMPENSATIONDECLARATION . - � - APPLICATION �O� P�UNiBING PER�i1T - � --�._ . I hereby aKirm that 4 have-a cert'rficate-�of consent to self �yq��q . � - � .�insure,or a certificate of Workers`CompensatiQn Insuronce, CE 8b7(REV.t0�8�j � -- - � - � or a ce�r�fred eopy ihereoE(Scc:38oD;tab:C:}- COUNTY OF LOS ANGElES BUICD{NG/4ND SAFETY f��,,�J � . P�olfcy No. �.��Pa�Y ��fi.[-��� �� . , - � . . � .. - .- � �L� . - ;. Certified copy is hereby fumished.- - . - � - i rt�a�icanir ro FEu mi�wtirdr oR rreEi svrtoirrc , � �Certified copy is filed with the cou�ty buildirtig insper � . � � Ao�RE55 ��Q�C 1 YU� �j-(. . : - .. flon.deparlmenL � . - -. �NUMBER- FfXFURE OR kTEM - -� : - --F� -- .-.. . . . , EMte 7`J �a.s APPlicant (-{�.�G/�SL-- WAIERCCOSFT . ` r lIX'Ai.�TY ac . _ _ i -- t N€ARESF �. e€rrrrFicnT�o�EscEraPriani FRora worzKeRs� anrN rue � ,�- c�oss sr. �i�-U I�i!� ��L t:Ylf' i - -- COMPEt�FS&FION INSURANCE - �. SHOWER � OWNER ��`�1 .. .. � � (TMs-ucFioe nawF�t br aompFet�d K tbe arork tnvolvad by . . r Y}(J� � - , ��� . � -: ; ihe�e�mfl if�p[6n!MVqdred doGan(5106}M Epfs.� - tAVATORY� � � p,�ppRE55 �1-� { ( � !C � �t � � : k eeMity tfiat in the perfarmante of the work for which-this - - � - � - , ; � permit is issu�ed,i ahc�l{nof employ arty person in onp monner ,�.� SI���- - � � � CiTY. �t�,F . . ��._.. - tEt.M4. �- -. - sn as to 6ecome subiecf to the Workers=CampensoEion Lows. OISHWASHER � � .. _ . -�-�--._.---,.-"-,-,��— . - . . . . -., .._.:. . __-. , -, _... _ ^.CfYNTRAFFEk"t V -�� - oatG •��.,��� �i 111"O�? : - -'CE-TO ARPlIGANT:+t affgr making-:thig�srti�itat$.af - . ADDRE55 _ _ - i -- - ---- --- -� -- - � .you�::should 6eeiirqs w6'ecc ea d„a�;woricecs` , . .-.sw�r�AhntNGraEz.A€ef�ii�r _,.. .�.Y. .�:_ __-... -- -- - - �_ .. . ;-,.:; ption, { _ -,- � -.�. .._ �.._ - ._ ._._t -- .. . ._- �--._ _ C�ompensakior�pr�swisiom of Ihe t<rbor Code,�yau must#orth- � G� T�-�:- . with cam�pfy wifh such.proaisions or fhis parmit�shall be - - �WNSFRtNKtERSYStEM � �q� _ . ! O v �CCLA�S �. deemedrevoked.�- -. �,� . - NtATERNEAtER -. . - �._ ItCENSEMO. �.. . . ; - UCEfdSED CONTRACTpR$DEGLARATION .: _ -�57RFCT NC3. -- PRFJCESS€D BY i _ t here6y affi€rrr tf�nz t am tir_s�d ua�€fer�ou�acu of GEwprer V�-� - .._.. Gas SvStFnr �-. _ C�1ttETS�.-.- � .. y/}� - ..-_ . . 4 (cammencirtg with Section TIXt6}of 6ivisian-3 of the Business- - Q�Ti,E7SayER - ..."" � . . � - --� �( - cmd.Professians Code,�r+d R, iicerue i�-in#r�N€arce arid effect. .,� s eE�Svsi€14t � .._ ...._ . ._. _ �_y. . ___ �. . ...__ S•-_' . .. - . � � €` F6ATft-��L �..- Y UDA#10R1 -. �-_.� ' ��i� 3 ; [icertsa Number�t�����'-� ��ic Class� � . � � � . - .�J . . .�.._ _.��u�'V�} V . . � �£l�� ._ � . . . . . _: ff - .. - - � � �:� i Contracfcr Qute . -� - . . BY . � - . � a i ��'[ � : C_.I _ � j - !am ezempi under Ser.�- . � �. ; - . - . . � .. _ - . . ._ _v�i`--! _ e.&e.C.for thts reason P���y theck fee � � : _.� -.-_. _. �e� .. . � . PLUMBtNG PERMIT ISSUING FEE S- � . � . � � - -- - � - �. ; ��--� . SigrwNre � . _ _ . _ ... �-� . � . . . . z� 2.G c�� .� � - . � . - ._ _ . - _ . .. .. TOFA[-FEE.. . . . . , . . . . � .. . .. .. ... � Pfan check appleccint .. � � _ .. � . • . - � �o a s-o-i--tir+ � - � . � - . :� � SINGLEFAN4!!Y .. - ._ . - � .. . � . �.�� e HOME OYJNER-6UILRER QECiARAEl4N _ Name ! o t C`('1�(� I � � � �by affrcm tfiat I am exempt from it�e Ganirpctqr's.4�ca�ts � -.. �.- .- �. �' ,. .' -:' .. - `-;� .._. .. �.::.. .-.. , ...,_,. ,. ..�_. ... .. , ,.- ._. , � �.-.a. �-, Address��.. �-, _ .. .. !z_. for tbe-fafPowing�eason(Sect[on'703T.5, 6usiness ond � .... � . . � . • z= ; L,(j,;ij i __� ProfessinrtsCade�_ �- . . �. . �ty � . . � . Te1.No. . . �. � - � �.��i � � !.�Qs owner of the properry,wil!do the work and the . - � . . � � - - ... . - - . Q 7•���-�� � ° � . �structure-is�rrot intended or offered fa�safe(Section - . . . . . . ._:�.. . . � - . . . :. i . .. J(}44,Bu:ineu and Professians Eode).- - - - � - - . � � - � � k - � CONSTRUCTfON LENQING AGENCY - __.. � � . . - . - . .. . - .. � � . . - . . .. .. -�� � � t hereby affkrn`thatthere is a consnuct�on fending agency for � . . � . - � - - � . �. - ; the.peifbrmance�nE the work tnr which this permit is issued . �: - - � . - � -__ � - _. - . . _ - ; � ($ec.-3047.Civ.G.j. . . , . - . .. . . . . . . _ . . �� . . . - Cender's Name . � �. . . � . . .. � . � . . .. � � . . . . ..Cender's Address�--- - � _ . . - . - � � - � � . . � � .._ i � -{�-certify ttwt:}:have read this applicotion and stale ihof the � � ' - �. - - . � .. . above information-is correct.t agree to camply wirh all Court�y -- .. _ . . : � . :. . ... .� � _ - . � - � ordinonces and Stare laws regolating Plumbing,and hereby . � � _ . . . �� �- . � � _ --au�t�orize tepre98nra�i�e5 bf �his-Coonty�7o eNer upon-the � � - . �. - . _ � - - t . - - a6ove-msntitlned property "inspetfion purposes. ' . � - - . � � � . 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