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HomeMy WebLinkAbout1209A (6) _ _- _ .�3 WORKERS'COMPENSATION DECLARATtON -�� � - -�ppCIC�►T�QdV IFpR-PLU�It1�ING RERii�itT � -��. I hereby affirm that t hove a tertif'tmFe of censent lo self 74A667A � - . - �- . � in4ure,or o certificate of Workers'Compensotion Insurance, . CE 817(REY.70/Sl) .- . . . . . .' - � � dr a cerritied copy rhereof(See.38QQ,lab.C.E � - CQUNTY OP LOS ANGELES � � BUN.DiNG PiNQ SAFETY �7� - � PQolicy No. Compony .�f�Efl�lfi/!f . � . . . . _ .. _ . - . � _ . - CertHied cctpy-is fierebyfurnished.-�� - FOR APPIKANi TQ FILL 4N(PRtNT OR TYPEj . BUIIDING �/p - Certified copy is fiied�with the county building inspeo- , ADDRESS � '( [��- �. Q f{� � fiondeporlmeM. �- � . �� NUMBER FtxTUREORIT€Nt � . � - .. ome '�-.S�-f's,�qpaE�4a„r �!n!!J E'!!.r Z- war�a aosEr �tac�7r p � �� � N€NRESF � � - � -- CERTlfPCATE flF EXEMPfION FRQM tM4&KE&5' - �"L .aAik TtIB . . � . .L �.. CROSS ST. e ... �� - �C- . f`II . -. .. � - Cf}M�NSATK?N INSURANC€ � - . - . - owr�rr � -�� -- - - .. (Tk[s fKNon�nwd RM{1f COmpl�ted FE the wark irtyplred by SHOWER - . . _ #h�yoeadf Ir im a�e hvndnd-dol►ms tito6y o.I..r.) uvAr�1 .... A�DD�REss ! C7�} !'�f1 e�1r �//�'f'T/ � . �1 certify that-in�the-perforrnance-nf the wark.for which fhrs -- - - � - � - �, permit is iuued.1 shall nof empioy any person in any manrter � SINK � - . � � � -CtTY � � . - 7�,ryp. - ... .. .. so as Fo 6ecome subjsct to the Workers'Compensation Laws. ptSHWA5HH2 - � ' � - � . �1,,,/r�,_� ,,,) � � � '� CONiRRCTOR - ' � Dote�s-��� aTplicant /7 f il ciC,lV QOTHfS WASHER .. ��- - �� i . _ _ ..�` '-E TQ APPLfCANF: I€,�g#tar making:tFus Ceitificate of . . . .- :, .,_ AQDRESS ,S'/�f'�/j�.� _ --- --- --_ - .- ` -' .-F SkQMht1_1uP�Rp��PiS7� ., °- . .. . _ .. _.,. .r.., �. '.':. ._ :_ __ _-_ ' -`- � �E ,tian Yau 3�4ufd�6ecome-aubjseE��#far S�ork�. .-: ___. _. c��r � . Campensotwn provts�ores af-Me Lahar Cade,yau m�st farth � - - - :�•M17�� - � � . with�comply with such proqisrons ar this �rmit.shal! be - ���R4FKKLER SYSFEM . - � � , SFRTE / (- - UC� ; � deemed�evuked - . . WAiER HEATER - - .�. - fICENSE-NO- /J. CL455 � � UCENSED CENVFRRCiORS DECCRRATIdN � . � . - � ,.. . WSTE2lCL t�. . :PROCESSEDBY - : !hereby affurti thaf t Qm 4icer�sed cenderprovisiaru af Chapter9 . - GASSYStEM -- OttTtETS .� �. . . _�._� �. . . . . .. --.i � .. (wmiriencing�eeith Section 7A0t1}of�trisian-3 t�f�the-Business .� OUilE750vER . ._ . � - i and Profexsions C�eF orxl my I.;ce�zse i�erz fuW fstrce n�affact. -. S eEA SrStFa1 � . . .. - . ... _ ?,. � s ! �tnral VA AFIGN n. [ � License_Number�1 rt �i`� tic.�Cfass �.�. 1c,+ �-. ..... ..... _._ . � URTE�� � ��� �� � �� -Contraciw ��RJI"ir�A"I � Dote i�����3 . . . . �� � BY. � . � � � � .: � �. ! u � _ �-.t am exempt undervSec. _ ._ . . - . . . � - . . � � - � B.&P.C.�fo�thisreawn- �� . .. � �� � v�i Plnn check#ee � � t�are: ` - i .. � � . . . . . � - . � -._PLttM81NG PERMFTfSSEtING�F€E.E. . . . . . � . . s � � ` Signature -. . . . . . . . . - . � .. . . - . . . - -SOTAL FEE. SQ . .. .. -���I �C��A - .. . . _ . �� . - . � _ �t.�s o.�.-.�,r} i - �� Pfon checic appficant- � � ` �. � . _. � � .. SINC>t.€FAMILV - { �� HOME QNtNER-BUILDER DECtARATION - , - Name , :. , .__ :-. _-_ - ( •��2�(,} E .. . .:. ... ..__ . . � -, � ._-- --_ � � I� '�y�rmtEwrlomezempsfromsheConhactar'sY�cer�se -:��,;_ _ ._ - �°�- ' °�'��,� �"��uc� " "`"" -� .. Lw. ror��tei.s!lewfngradsori;'(Seetio�7tf3i.3.�Evsireess'a� � . .. .. _ � . ._ �. �. _.__� . _ „ .�.,. _ �. .__�._ �.. ,. �....,� .,.�.,�_ ,�,,., Gry - TeL Na � Professionx Cotte}: . �7.�9��� � .. ❑_�1.:as owner af:�.lhe - . .. . . �.- . . � . � .. . . - . _ . . � property,.wilt do ihe wark and tMe . . . . -.---- . . shvcture is not intended or offered for sale(Sechon - - - � � -:� . - - . .p � ' 7Q94,6uainess and Professions Code). � � � - . . _ . _ � . -... �CONSiRUCitON-tEfIDtNGAGENCY- . . .. .. . � t hereby aHirm that there is o construcf�anlending agency�for . - -- - - . � - . - . i � . the performance of the work for which this permit is issued . . � . , - : � - � __.. - � � - � � � [Sec 3047��Gv.C.}. . . . . _ . . � - � � . _._:., .. . . - . . _ . . � . ! � Lender's Name� . . . . . . � . . � _ � . . .. . . � � - . � � .. -� : Lar�der.'s/4ddreu � .. . . _ .. �.� . - � . � � . ... , � i cerfify Ihtrt I have.ead Ihis application and sMte thnt the - � � . � � � . �� � - �i above infwmaiion is correct I agree to comply with all County . - �� - - � -� � � . - -- . - � � - wdinances and State faws regvlating Plumbing,ond heraby .- �. � ��� � . . - - � j .. . buihoriie�representalives of this County to enter upon the . . � ' -��. � - �- � �-��-- ' . . . � . � i ... -a ove-meniionedprop �fo�inspection purpose:. ... - - . . - ... . � - . .. .. 4 SEE REYERSE FOR EXPLANATORY tAM('sUAGE f _ _.�_ _ ._ _ �_._ �._ �.��.�..,_._____.._ _._ _.__-.----___.—.__..------- _.-_. ------ -_ _ � __-- - ---- ' _ _._.— •-___.____, �. . ig fure of Permiltee . � DWe .. .. � � . . .-, . . . .__. .. . . . . . . . �. � E . . 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