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1200A (6)
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:�. ._ . .... �`u �� � . ... ..� ... �.�.. . •....-� � . . € .. - - � �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 - - �� � . � . . . 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.e of rm�ttee �pare ... _... .� _ . �. .. - � - ..-.... . },_ . '�. Cf� . . . '''4 � � N C .� m � � �j C ��V . .. t N# . Y O Q. O , �a''.b C G.0 . ' {Y� S.� � �7 3 D-� u p C Y � �p ��� C ' u M 3 O M,vi O p�a p�y�j m L p �G p �n ?9�L . . � C � � , � ..�. �� + �^��.. 9� a� p c �� � �n > �41 d 1� O D d�.� C O .C C C'O G C ^- �} N S'� b j „ : . . U � ��Yi U�'^�> � �n A p W� � � G 3 � • u O•� - . - ' Z U y .p Y].:� �E �d O O.0 O '�b,.0.'�O O'O p �O d0 � . . , . . p s`oQ�, m yc� o �� �rou � oamoo �, � a Ec � E N�.ec,�Q. � � 7 •` m 3"$ co E ci.ma ' V ' C11 d C Q `" O C m � D 0 t ^t^ C�d � m O in >'m j e«: C j 2"oa � �. � , ,.. ¢ Q a� a U a � o�'E c °.` a o o `o� a� N oi c m«,. w � � % �i� � O.S �U af X O O� m m 0. O n� N� C/ O.�°.. N� . � . C � o � � m �"g� c �.e o� � '..$ µ' E o N �, � °'3 a �p-z a c N o m... o m..-_. d � ...� Q o�o po :' m..b,� a, m �°,o '$tc „ on,ro'flo'� o c '-' . a _ u �° hmyLx- c .:r` mro � Qm ��34 � t N� b N � �+a C m � Q p � d a .C'Q C '_ �h�'= a. � � � G ,C��... Sl. W«,.,s.c m� � � a y �o ti� °�„- ��.p•�' �'-' °"-' °�vro � "' 3�; �° °' m �gallo� a, a��� �t0 ��aE-�o g.'n-° e�i, u � F O '� 3 c a,o;o.c-.o�o >.ea`.r,Ti� u �z m � n , °` � � , ao � � �,.�c�..ov^ ° �'� ° �[��n:r.a�� oms a at1 0 � '�„y , r'� tc � e'oec� ��� �o ,���3 � CE � zj ' m ��s � � a�i ��' mu�„°�^ �'�O . . � L a v E . . � . . 'I��. li ' " �I`` � , I � . a Z �, a O � e. N ? � � . ''`.M.��, ' . ....,,,. r.� . . _ ..:.F -... .� _..s . ,� .� . , � � t , � r � . � '< �- ..., � - N � . � �t ...+ . r �4'. � ' .. , . Z � J� Q Z � � U 7 � Qa . � . . . p � . . - - O „� . . , � , � , ... Y r�, . . .... ., . "V ,p � �. P , � . � � . - `�-' « � .� �.+ a p_: y� �. ' . > 3 �, a � Z Q� & 3 � ? ia � �' � �� 'C �n �,.a �u yr .m �' .- q o 4 . _ P Z �Q Q N Y = CJ � „" Z'� 7 u � � O � . _` —,_""'._.J.----�"."___.--..m..---., ..�-.--^'�--'-_.._----__