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1225A
� . � WORKERS'COMPENSATION DECLARATION �� - APPl1CATION��Ql3 PtU1VlBlNf9 P��tMIT �6 � � - f�hereby affirm thot�l�have a cerfificate of consent to�self � � �bq�7a . . . . . . , insure,or p�cerfificofe of Workers"Gompensation t�surance, �CE&17(REV.40�8tj - � � � .. � or a mrt�fied copy�hemot(Sec.3800.��.�C) � C�UNTY OF LQS ANGELES BUIED{NG AND SRFETY�� (± ' � �cy No.� - ComPanY lJ�=►yt5 . . - . . Q� ertified copy is hereby furnished. � FORAPPLICANTTOFILFlN(PRINTQRtYPE) �f�� i . ��-Certi#ied coRy'ra filed w4fh ihe county building Inspec. � . � �'� ��Q K��� ��.L�.�S . _ � � • �tiom deprntment. � . . � . NUMB€R � PI%TURE OR ffEM @ � FEE - - � - - LOCAUTY �1 . tkErB"]—S—$S��tftonr !}tVl3t7 �► wn�rzciaser ` .... NFARES4 � .C€RFIFtG4TE OF EIEEMPfI�N FR4M WORKERS' � --^f/ Ba�7uB: : . � . -2 �- causs-sr. ��. � . . . . . :.��. . GOMPENSATION 1NSUR.4NCE . . . . - � 6WNER : � ' - . - - {Thit-feetia+need aut be eemplatad'rE Nw auk inrolred by . St�CiwEFt - - - - ` .. . . ,.. 111!pw�nil 1}for one bVrulred d011qrs(�100}of(ols:� -- tAYATORY � � ^� Q RESS �-. (�-� ! � vV - ' �--F ce�tify thaf in the perfarmaace of tfie wark for wfiich this . ... . . . . . . . - � � permit is issued,I sFwll not employ ony person in crny.manner Z�- �� � � �'� � - � (�V� - - 1El.NQ. � - . � . �o as ta become su6ject to�ifie tM1�arkers Campenwtion laws. - . , - - . � - . .� � . . . � R�SNWASWER r'� CONTRACTOR .. . . .. Dofe�'�'�J T^rltcOsll� !'1f U�� t .. CLOTh�S WASFlER � rr. � -- _F�' "E FQ APPLfCANT: t4.-oftu makmg�lhrs Eertificate 9f -- - �--�� rtDDRESs -- - - - - � €f� ,4ico. Yw SEiotitd becume,Ss�.+jeel,to�fl�:N(Qrkers' -��' SWiMMtF�FWE R€CE�if7R _�" -: fEt.NO.-_ ;_� Compensatian provi�iQns of tke tahar Catle.You must fQrth � t,e,wht SPtittdk�ER S�[SiFpn . . ' : . . . � . :... .��� -� _ mrtth-comply wlth�such pravisians w this permit shall-be - SFATE -.-.UC. � .. .�desmed Eevoked. . . . . . � � � watER FiEafER- -. - . � � . r. tICENSE N6. . . ' . �qg5 . . . .. . .EICENSED CONTRACTQRS DECIRRAFIQN . � - - � DESTRICi N0. - . .PROf.ESSED BY -� - . i � ...�.. GASSYSIFM - �UTLEFS ,-�..� , _ c t hereby offhm tlxit t artr!'�censed crader.P�'oyisiQcn of Chapter 4 - -.--- , . _. __ . .. . _.: _. .- . . � (commenctng wiih Sectwn-7Q00}bf Qrvrs�ori 3 af the 6vs+ness . O[�7�Etg Ov�ti - � �� and Professiions Cqde,aad my kicense is Gn full farce ai�d.eEfec!. s v�R SrSrEM - - . -' _ - . �` es �i'`1�� �3� `�.a"�`�� ����i�' �tit���o�t : � i ' - I:ice�se Number�,. Lic:Class� . - . � t�t,IC?�rtlA" `� 7'��-'"`F�..I�` BYAL � Gontractor �ate . - � _ (� F # !._F .�om exempt under 5ec. - � __ . .. . - � . - .- � � - _ . . .a � . .. B.&P.C.for this teason - � � . . .. . � .. - - �� � Rlan theck fee � � - ,� , -Dare: . . . . _ . �u�neEr�c�an��r tssurwc Fe�a (� �1 2 2.�A s�s,xir�e ' � - . _.�. - . . .. .._ .. . . . . . F4FAEfEE.- . _ . .. .�+.a�a a a�r.�4, - . � . . . . . ..-. - . .. _. _. _ - Pfon check vpplimnf .. . . .. � :. . � .- � �.��i�J�Q . �: . .. . �SINGLE FAM4LY -- . . . . - . . . � . .. , HOME OWNER-BU4CDER DECIP.RATtON . _ Name - _ *�� � I I� iy affirm th4t t pm exeenpt fram the Contrpttar's t�tenae -� - �� � �� .-_ �._ :-. .. Ym :" _._2.._- =--- �-.`—`��j" . _ �. _._ �..;��., .._.�. �--- ._ =-_ -=`_`_ _,r . A_ _ _- , � La. �vrthe-hsltaw'tng t�son`{Seci'ron�763f.5,-Eusinass rrnd-..�_. --- . ! ���s� - Frofeuions Code�: �- . . � Eity - TeL No. - �' ❑ .1.-as owner.af the�proPerty,wiH do the work and she � � . - .. .. - � . . .. . - . . . �.. .. - �' � . sfructu�e is not intended or offered for sak(Sedion � � . . �. . � . � . �� �. � --. - . . � i � . 704a,Busirressand Professions Code). � .� -.� � � � � . _ . . . _ : : . � . .. C6NSTRUCTION LENDING AGENCY . . . . . . .. . .. � - . . . � .. . _. . . . . . . � "- f her�k�y uffirm ihat there.is a consfruction Iending aqency for � - -� - - � � - - - � � - - � . - � - � , � � � . . � the pedormonce�o4 Ihe work for which this permit ts issued . . . . . . . . - � � . � - - . " . � _ �. � . � ! � (Sec.3Q47,Civ.C.). � � . . . � - � _. . .. � . _. _ . . . . . - .; . . _ . . . . . . - . ! -. Lender's Nome . - . . �. � . - . � .: . � . . � � � � -� tender`s Address � . . . . . . . . � - . F certi#y that t have read this appiication and state.thoi.ihe � . . � . - . - . -- � � . . j .o6ove i�{ormatioo is cor�ect 1 agcee to comp�y with alt�p�nry , � . - � . - � -, - - . i .ordinances and Siaie taws regulqting Plumbirtg,and fiereby � -� � � . � . nutho�iie represenlotives b4 this Counry fo e�ter upon the - - - . � -- .�. . . . . . � - � . . � - � - above-menfioned prop for inspecfion�p�rpases. ' . �� - � - � . . - - . _ _ _ � ' SEE REYERSE FOR EXPLANATORY LANGUAGE _ ! .. _ - -! � ------__ _------------ ---- --- _--- -- ---- ' .SE foreo ermi8ee � - Dote .. . _ . ____._ __-____-_,___.._..__._ ._._..___ t j x S �'� .,� .., , i'-.. . Y'-. ''ti C�'O TL O ��� � »- u c rn o � .o 'G omrycct � o m � "' Q� O fl- p'a . D. . a�- � � �^ a '� a a� �" m m o �c Y Q o ;� m N �;�� m o= 3 0�v°� ro.'c ° o c�° �mE� Y ... s - o�o rn a`. � ' 3 ai r � �,-�. 8�� N ' O O w ,n C d U N t u O � oti rE o m o��c'� ° �,�-.. r °u� c 3 � m o °-O e� c . fl � c � m3 0 0 � � c'c mrn�+ m �, ° o � c -°u°'c' °� amao � � ° '�o� � c o o� m o o'�.�c -=-ou o ° � o �-d °' " o � c, a� � o a •- .; m � o c,y,z y� �. � su�° fl.�:«. s �d•> '- p � o o � a 's � � �� , >a �� �" E o °' fII � T� E m ° ��n�y m '" c m� �es o � Q p O� T "S +- � 0t } Q, O••- p Q'�'" q t+"O�t�L •s- �• t h O . ' Q� " m � � � d, a. a C 4-p �p h ,.- �n 0�,� .. � 0 . . � aod o 0 o„Nv�°,a ,°'cg°o `c"�N a m°v °s o � s �z} E � Ol u S. 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