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HomeMy WebLinkAbout1217A (6) w1 /�Qp �J� p� ��/� �� WORKER5 COMPENSATKNJ DECLARATIQN - - :. � � - �P����AT�Q1�1 ��/fZ r LU/Y�B��G r�NYI�T ,.. 1 hereby affirm-lhai"I have a certifimte of consent to self 76qby�p . � . � insure,or u cerfifimte of Workers'Campenwtioo InsuranCe, �E gp(REV.-10/BI) - - . . - � � - � or a certttied copy#hereof(Sec b.C.} CpU[�fTy pp LQS ANGELES BUILQiNG AND SAFETY x` ,� � � P❑oflcy No, . - Company .:(��� � _ . . . . . .� [J� . . �f Certified copy is here6y fumished. .FOR APPLICAtJT TO flLi fN(PRINT OR ttPE)� . BUICDlN6 � : .� �.. .,..., . _ -. . . ��Certifiect copy is 4iked v✓ith the covnry building inspet-- �� - ADDRE55 ��� / - fion de art�neni. - - - NUMBER FIXFUREOR ITEM - �- � - � _--- � � ... IOCAtITY . Dote�Appli�an� . �..-- _ W2.iFq.C105E7.._ . _ l : . . _.. .� . , _ � NEAREST . � -, � �� � � CERTIFPCATE OF EX€MPTlOM FROM WORKERS' �$,/ Bn7H TUB � -`-a„ � crzoss si. _ . � �. - . .GOAhPEN5AT10N ENSURANCE� ..- OwwEa.. - . �. � SHOWER ... . WN . �4Tftfa s�ioa aesd aot ba-ceunpltt�d��Nq-work im ohed hK . �- - ' � -- t6s��rmtt Fs fw one humkod dolMrs(4t00}ur tau.} wvat6a� r���` Q �C.Gt� ��.ADDRESS _ _-4 certify that-in.the performance-of the wark for which this . �ry � � � . ..pprmit is i55ued,t sF�all noi employ anY PQnon in dny manner � � S�NK - - � 4 .� ��y- ��. -- - . . .. �. ..so as to become eab�ecf-ia ihe lMcrkers`Eromperuafian law�. DISHwRSHER � � � .. . '�,�� .Datel`*��"^� n,f, 'nn�`'lr-i.�i.'��I- � � . fONTRACTOR `�f . - : �[.� p� CLOTNES WA$HFR �.�.+� � i . .t�F '.E Tfl APPLtCAFtT: fF,ruher making'this Certititate nf _ . .. _ - AaDRE55 -'-- _ - - -_ - E( �fi�n. Ysw--.s6asufd_-beca�s-subjoe#---to�-if�r�SNorkarr� '- 5��--�-��F�b"�`mT^a : - -` �7 . Gompenaqhort provisiansof-tht kabor Code�You mus!€arth- - . Cm' TEt.t�3. • tAWN$PRtNKLFR SYSTEM ; wF�t eompky wHA such prorisians m fhis permit-shott be - STATE � �C . . dEemed r�vDked.�_. .� .. _ � . � WRTER HEATER � � �� E(CENSE NO. �q� � . . �€ _ - UCENSE6 CONTRkCT6R5[�CLRRATtON . � .. � 615TRICE N4. .. ._.. . �SSED BY � i . khereb afFamthW-tamticensedunder - p� . Ga55YS�EM -- .^,.. - . . �- . . :-.; Y proresiorts o#�Gho r 9 �. �1����. f} -- � (tommencing witEi�5ectian:3U06J of E3ivision 3 ai the Bvslness-. .. dUTI€75(}VER - . . ..... .. . `�', �. . ... . .. � �.. � ortd Pratessrvns Godee and my=ticense ts in fult{���arid effed. _ - s v€R Svsr€en . .. ..._ � 7• s -- �,� v toaTEoru . � � �`ll `q � I CicereeNumb�� Ec.-tlass .... : " - -� `� F S� - � � . . . . . � fINAL � . . . � � . .. � � .. . � i . � Cnrttracb �� _ Date � �� - . . . BY - � . � - � i Q � 4 ._4am.excmpt�nder .ec.. _ . . . ... - -- . _ . . . . - W � 8.8P.C.far this reason . . . . � . . . .H- ? . - - . �EOCi{f1EE�C�Ce- . . -� � . � . . � ��:.�s ,�:. . _ . �EMia-� . . . - � - . -. �. . - . . � -...�� �-�.7-k :�.i . . .. . - - . �PLUMBtNG PEkM1T t55U1NG FE€�- . -t - � � � .. .. � � SignaFure - -� � . -- -. � . . . . - - - - #s s e c �.`G,. - . � . _ _ . . _ . . - � .. .� _ TOTAI FEE_ .Q('� .._ . . . . . � � - . . . € � � - -SINGLE FAMitY . . . . .. Plart chectcapplicanf _ . - � .. �.__ -- � � ' . . . . '�-• �.(}���J�O� - r � HOME pWNER$UIl�OER DEC�AhRATfpN __._ � Name � � . . . . . . - -'��'� � .���,�r�� � t' iy a4firm rhai.l am exemptfram the toneractq�zt�canse, _- -� - _ _ _ -_ ---:..t . l��.- roe-the foffrnvFng reosnvi'(5eceto�s`TQ3F 5, Business and - �•�rea�--: ` _- _ __ - _.�. . _ _G��.� �._y"- -.:-:� ProfessfansCode):� . . . � tiiy � l'7e( No. � . . -' ❑. 1,as owner af tFe propert�t,.will do ihe�vodt and the . . . - � . . . . . � ii! -:structure is nat inter�ded or offered for wte(Section . - _-: � � � 7044,Business and Professiarts Code). � � ' � . � � - . �� � . - � .::� �.. CQNSTRUCTIOM1i LENOING AGENCY . - - . . . . . . . . �- - . - . . �- .. .. ; � 1 hereby,af£irm thut there is a consfrucfion Iending.ogency#w- -. . � - . - . _ - .- - � - fhe performance of the work for whith t6is permit is issued - � - . � � . - .� .:_. (Sec.�3097.Civ.C.}.- . � . - . . . . . � .. . - � - � � . . . . _. . _ � . . _._.. . .. - � .... �Lender's Name � . . . - . . . . . . _ . . . . . . � .� .�. Lende_r's Address ... � . . .:. � . � � � . . - . � 4 certify tho!-t have read if�is application ond siafe thot the � . __. ' - . . .�� . . � � ,, � � � obove infwmction is mrrect.I dgree to compty with oll County � - � � � � . � - �. - o�dinances and State taws regulahng Pfumbing;and hereby . . . _�� � . . - � � � o�thwize�repre5entafW�S�-of'fhis Counfy ta-enfer �pon the . . . . . . . ..'. . . : .. - � � abore- nt� ned prope Inspection purposes. - .. - � . - � � . _ _ SEE REVERSE FQR FXPLANATORY 1ANGt1AGE ' _ ����.Q-�.,�- -- -- - --------------------------- ---- : _ . __ ,. �1 . �8i na re of Permiuee . . pa�e . - .-. - . � � . - . : . . _ - ' K �II , . . . ro � � V S 0.�'D . . , � '� � O�� 11 ,. � .c d d �� m N °Y,d 0 ° D °-„ 0 C o p . � , . . ^ O`n. �H .p .?ip� doc Y �Q „�'��. _ . � . r, :o °�,�� rn n. m� m_c � �p.«-o t-°o,�^ oo� �mamc�v� .s« m ., � �,= ° o � � � �g' � � cv: � o G cv o � ,� �°'b�" us £ �a h o ��� � cn;� m � ac ��- -5c � c ; a+ o v °� oai ��� > Ey o ?+ c 'd � a3.o } a`,oao � Z s� c � 0 4�;° D E m c o�..°c 4 a c � n-'a+ t o m ;' O L ��.°.��c, t+�-�'"m ° � � �'w ° � £ o i,m °o- � • - •- .� .•- r 4�... 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