Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1225A (6)
� . � 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 . . ' . .. . .kICENSED 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 __.. � .. � . . �. . � . � �� .. � . � --. - . . , � 704a,Busirressand Professions Code). � .� . � � � . . � - - �� C6NSTRUCTION LENDING AGENCY - � - � - - � � �� .. � - - . . -- - � - � - - - a "- 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 ..-- .�_. _ � .._.,,,___ _ � i "' �'�� �' m��� o o ca m o o m� c ��'��'o ,,+ `o ' oQ3 �oN °a3o.n � oc '", a� acc,c° ' „ 'i.-. �r• � � o m � C 4�v'�.�c o Q� °�° o o , . tJ ° 'o � u °' � moc ° � °> �, °� wro .mo,`� � �, U ui.c -°e O .c;!joo � ooE '" Eom� � v°� m.c° Eyoc� ,. m o . ° 3 w u ' ,°, � o `o � � Mo �`� �a° � �roo �� o �oaa Q � T �; �°' a+ � ' " � �� m„ o ° E; oo ,°„ Ua °Qmo "` � Lv� >. Eo +mco aaeo W E :.'.c cmE � o ac.c �' � s- o � rn� ° t m o a"' $Q a `m o „„�, � d`D �. � ° c� � o a�.c°o E a o 0 0 ffi 'ao`, y= o ' °- W °' 3 ° � Qu ��r, Xo '- � a'o.� a� o` _em� � o� � u o � oV � � a cd � •• o m °'� `oh� °� _ . � �.� � � L l.'p O fl � � C �` � d� N �� � 3..�ti�.. ✓1 y � r� — N U �,� H"' :^ N y �... v- ,C m � �� p � . O . . . . u�, �s,� � � p u ca a m am a� o m�° E 'o �' °_�—. o � n Z o q '� m �— u psro b'a, c c e 3 � m � 3 n, � � � � a m '�a':.'-�`o o,�.•i-�o :^ �° `o�o �, E a � � 3� ae o.c"o-.°` o'vo a mcc � y N � m� ` E � a a o o � m $�a p �. ow .P"+ =�= ° E � ° m �, y „a.�r � o � ...— ��v ;; � E'nd,c'� x tj m n m m m„ a ov�'n ° i"Qk'!`-+'°`�`o o ` � � � �, m a�i � p-� � m c`u � �M c'b � �=" oi � ac`Q E otl � 3 s;m' ° `o 'a�EtiH �°� u'o° -�'��3 3 � E o °c � m o � � + :�� ��.� - i i � �'-' ! O i z i �N . , �' �. . � O i � I N Z ,, � . . . � � _. . a. : . . .„ __ ..,. .d . -r .�., ` 9. +,.•^� s'�� �I i � ^ ' � . . H �� , - ��I . N ' „. ' ., ��I K � . � � ' . ���, . � � Z — � � � � � � � � i � , � Y �y1 � W ' • ��II . . � z ~ � H � Q i II � 3 `° i � � o ; I d °L Q 3 � � � Q z � � �a II � � a � 3 � � j �u��i � � � la9 � �x a � � Z z3 '