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1200A
aPP�ieaTia� �o� P�vnn���� ����u�r '� WORKERS'COMPENSATIQN DECLARATI6N - - - � , � . F hereby-affirm-thal-4-huye a�eertificate�of consent to self �6qyblq - � �,I! insure,or o eert"rfi€We of Werkerr�Eomperrsatianinsurance, - CE Bt?(REY.i0�91j � . _ . . - � - . _� � or o cerrtfed copy rhereof(Sec.3800,tab.C,.,y}�,� COUNTY OF COS RNGELES BU4LDMIG AND SAPETY Y � �p� � . .Po4ic hb. . . .. Compony���+EN[�� . . . . .. . . Q�7A�'T O � ;I . �� _Certified copy is hereby fumished_ � � � . . . .... . . . - i - f4R RPR4GNT TQ FKL IN�PRINT QR TYPEj. BUItDING.. v. ��„ _ ��a I . �tertified capy is filed with the taunty buiPd�ng inspeo- - � ADDRE55 � (J I t[on department. - . . NIiMBER FI%TUNE 6R fTEM � � � �Q�q��TY � ,C �s s , � Dttte��."�i•s .Applisarrt-�.,��tn . ---. ��a_.- .iNA7ER.Ct6SEi ...�.� . . � 2.,., . - � - rvFn�sT �� If a►�} �t`1�.1� � - ` CERTIFtCAfi€DF E7(EhSPTfOt�f FROM WORKERS` 'Z�' Ba.Ttt.itta - � - � - ��� � [Ft055 ST: ` { ,. - . _ � �COMFEF`15ATION€NSURAIVCE��.. - OWNER � .. �,��ry� ..- { -. �.(TAis�Wion need not he compFatw!N f6s�erark Enrntved 6� :. - � SHOwER-- � . . � . . ^C.�f! ' . . - � .fhe-psrmk-&for ona-hundr.d doilars-��ftq}or�lesn:f. . ;�„� tavarortr . . . � �. nuu. � t�s {� `t� _ � ,- ADDRE55 . [ • �(.{ � €certify fhot in the perf6rinnnce of the work#or which thls - ' . . .. ,- -permit is issued,t shall nut employ any person in orey manner �NK- - � - �� r� �Ct7Y -� �-.CQ�i,L- . k�,pp.�. . . ���!. - - so crs to become su6�ecf�o rhe Workers`Eompe�sation Lows. . a�µ�rASHER � � - � .. . � � �e �"'. m�vtsacroa � � Dote �"Sc��:S a g4ic�nt�„���{e� - CIQiHES WASHER �^" . �. ... �� . � , �' 'rGE TO APPLfCAhIT: [f,-.aftEr.mnk.tng..ilt�x Certificate a€ .._ . ... ..__ . -, _.,.. __ At76RE55 _.___.___ _ .. �_ _._,_ _ ___ _._._._ _�tfSr;-�scr€sre�e -� -`; - - rption ir«+-..shoutd k�seame aultjetf-ta-3he-._�?otker�_ -��= - --- — . ._�_ . I Compertsatian prov�srons of the La6or Cnde,you m�st forth- . � - -- - �� --- � TH.NO. . . . � �� with comply with such provisiOrrs w this permit 5haf1 be �����1NK[FRSYST�M SFATE n. � deemed revoked. � . . � � - Wa7ER HEA'fER . - . �� t�CENSE NO, V� ��� - . � - F - . .- . LICENSED CQNTRACTORS Q€CLARATIOt3 - � . p�SiRfQ�..� �. ���gY _ [ GASSYS4EM -_�; fJk�icETS r+- � t Fmreby aH'um tfwt k am f�censed under:provisiont of Chapter9 - 1�� . �-._ - . . . (comme�cing veith Sectian 7(IOp}of 6rcision 3 af tt�Business ptFTiETSpyER � � . . . . :. . � . and.Professiens Code.a�my tiGense is en fu4!#wce anf!affect _ .. 5 PER SYSTEM �y��i . � �Y..� i } ���#f!7�� �'.�.� U�a����Z f"t E��� VAC►I?ATION v : ticenseNumber f7i Lic._Ciass . � , ,������ - �rrta,t � c�„�a�r� om� sv � ! - �. 4 am exempf Under Sec _ -. _ .. � .. _ . . . � � 8.8P.G.for thes reoson� - . - � . . . . . �'� `�(j(}� � P[an check fee 2 . tzaee:�. ._ . .... . �Q �� � . ... ..� ... �.�.. . •....-� � . . € .. - - � �PLUf�tBlNG PERMtt ISSFtIR1G FEE b -- -$ignafure - � . . . �T t _ , . . . . .. _ � .. . -. -70TAL FEE �- "�S 1P� �C- - . . - . -� ( '��I�.G Jr Q - i . . .. . .. . . _,. . , �� ._ �� � � PFon cfieck applkcant - . . . � . . . . . �.. • � •7(S.J�(}_ �. . ; .. - SFNGtE-FAA4ILY� . . : . . . . . �". . I - F1Q/11E QWNER-BU4€6€R DECLARAFf6N Name � - � - __ . . . . _„ _ . . _ . ,_.�.r. . -' � --- - �._ � . � .._ .. t �704 8S. � g sby afhrm 6hat.[ttrn exe�!�rom itis Ga�rMactar'sEicec� :.;���&�,--- -- FE.#or�riie#oltowirg reasen�(Secttan�-763P.5,�vriness and - ' � � - - � Frofess€onsCode}r� . . . . , � � CitY � .. . � Te4.-No. � . . . . � � ❑ �-I,as owner of fhe property,will do the work and t6e � . . . . - � . _ - � � � . �- _ - _ . - . � � - � strocture is not intended or offered for wle(Section - � � � ---- � .- ' --� ' - . , . . - . -.� _�?044.8usinesspnd Professia�s Code). - _ � - - . _ . -� .. . _ _ t � ' � CONSTRUCTI4N LEN6ING AGENCY - -- -� - - - - - � � � . . . . _ . . - . . � - _ t � t hereby aKitm that the�e is a wnsf�ucFiort lending agency far - - - �� � . � . . I. j . the performance of ihe work for whic0 this permit is is:ued _ - � - . - - _ - � ..i :_�. � (Sec.3Q47,Civ.C.}._. _ . . �_ - � . - �� - .- .: . . . . .. . -' . . . . . . . � - . . _ . . _ . . .._ . . . _ � .{fln�ter`s Name - - . - . .. � . - . . _ .. t - - . . � . . . .. . . . . . .- -.- . � : ..:. . . . _. � � � Eender's Address - - � ._ � � �. . - . . . � � i k redify,thvr.f have read thiz applicat'ron and stgte that the . - ... .;." - .� . .. �- - . '.�� � - � . . '....: ; . a6ove�irt4armation is cwrect.t agree to comply with alf County � - - � . � . . �- . .. ; - ordinn�ces ond State laws reguloting Pivmbing,and hereby - - .. - - . �--- - -_ . � -� . � �, _ � autharize represantatives of this Counry to enter upon the - � � - � � - - - - �. : . above•mentioned praper+y inspecfion purposes. ��. - � �� - - _ . . . . � .- . . �w ���+� SEE REVERSE FOB ERPLANATORY tANGUAGE . �7 ,. - Si t.eof rm�ttee �pare ... _... .� _ . . .. - � - ..-.... . r. ,`:4, m� �. �u q O L a � ��'.�C �, c•_m a ° v�'^ �, :D � a �� N "N Q �� � � O O � . . � s .0 N N L'-�3 O p Vd O ? O � �'QO C,�4.O��e . . , , . . , ' " ' �.riuN ia ., yvimL 3 �o dm � �o � , x O N'N N c d Y � � � d r �� �� u•y� � « ... tl�:->.�£o d o c��O � � •7.. -�� �° �' � m o fl-° ' � � . G G C"d0 ��II1�N 4i N D � d G ^D.�v.� �C Q.N O �'��r�� � � � . 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