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HomeMy WebLinkAbout1218A , � �� W6RKER5'COMPENSATIpNDECIARATION � ACP��CATIVN i�QR PLUMQ�NV P�I�/YfIT � �� � t hereby aKirm_that l.have-dcerti{icate o#.consent to self 76Ae67A. . - - � . '. .. insure,or o certifecata of Workers'Compensotion Insomnce, ...CE&x�(REV.16l�1}. ...- ---.. --. _ .. - . .. . f or d ce�ttf�ed coPy�hereof(Sec. �ah.C.y COUNTY OF tQ5 ANGELES BUILQING AND SAFETY p.� � Polity No. . Company �t � _ . . . .. � . _ __.. _ _._.. . � .p�- . .. � QCertified copy is here6y€urnished. � � . - FOR AVPIFCANT TO FILL tN(PRINT OR TYPEj - �R� � '3 � - � . Certified copy Is filed with fhe mun#y building inspec- .� tian d�rtment. . NUMBER. . FlXTUfiEOR1iEAF � . � LOCALtiY _ . � ... 6ate ^ � Appl[�ank . � � WATER CLOSEf � " -� NEARE57 �� r ��� . t . . -- -CERFkFffAFE flF�EXEMPT(ON-fRQM�WQRKEFts`_ . . BAiH n16 - . - . . _4 Z �- CROSS ST. -. � � COMP€NSATtOP11tYSURAl4C€ . � .. . . qyy� � . . � . (Thic sKBon eaod mN!w complete�lii th�wsAc inaelwd 6y � sHoatea - � .. . Mai! . �.� r ."�..-.� ...- tha.perrmk Es for.en�kundw¢dolian_(f100)or t�s�.} -.- t�ivk70RY � � . - .� App� Q� (` . .e(,(� . ` . I certi�y tFat in the perfwrtwrtce o#the wxk for wbich rhis . . . . _ .. . . E . peFmit is issued,I ahal{.�W employ ony penon in any mooner. �� �NK- - . . - - i CiTY � . � - .TEt_t�I. .. . � .- :-.E so as ro become subject to(Fe Workars Compensptiqn laws. DlSHWASNER � 4w_{1 �'- COMRaRat � - . - �.._-:� .. Qa�C�Plicant�►lCI"�.� � CCQR�IES WASHER ..+ A�DRESS.� .. . . .i . ^*ICE�TO APPtECAP1T: if, after making-th�s Ccrtificaie ef �����F�_ _ �.- _ _,_ a�_ _ �a� .._� _ ._. __ _. ��_,_�. am�� _��_ r pfion. Yau�:_�h4�k3,�came sub[ecF; fq the �erRers" --- -�' - -L`tFF .�..: � --:-- � � -= �-�Xy-..-- --�� - - - ._;. ._._. _ _— �- . __.-.,:.:� � ...,ipertsatiort provi5rorti-of tht kabor Eode,'pov erei*sf�ortft- �- LAWN SPRINKtEH SYSTEM vrcith comply wFth such prnvlsians or this permit shalf be STA2E UC � � � � . deertsed revaked: - - wA3ER HEASER -� � - - ,� UCENSE AK)� � ClASS � -� flCENSED CONTRAGTQRS€7EEtARATIQN .... - . � .FkSratCi a. ' � PROCE55€Q Bv -- � 4 F�ereby aEEism clwr�om tice�ued under prov;sians of Chapter 4. -� 6n5 svsrE,�n � -c)ureHs� .,.�.. � ���.. . _. _ . .. _. � .` - (commerteing with�SeUicui 7EX}U}of Division 3 0€the B�ainess . pkiTtETSQYER - � -� }, � and Prafessitx�s Cade,ond cr2r_lice�se is in#aslk fares and effect. - - 5 PEk 5v5fEM � �� g.. � Fl I ��� YA /�Ti�3N � � 6ATE Z , � -Cicense Num� �� iic C4ass . .� � ,. '.. - ' ' - . : -j ' . `. . _�. .. . . . . . . - _ � � FlNAl . .� . - . . ��ct : ConhacFo � Qate�_!.i_=D�- � .. . ._. . . . � BY . �. . � .d_�. . . ❑ . . .. � . . _ . � . - - - . .. . .. . SJ • I am exempt uncier Sec. �-� � . . _ . . � �..- � ---. - . . . � � 6.8BC:for th�s reason .. ... � . �. . ' . . - �� .� - � - � B Flan check fee � z € - f�sre: - . _ .. . . . . . - - . .. . PLtlMSIIVCa.PERMkT ISSUING�EE S . --�Q � �� - - � -s�'•.j c�.��:Qv E1 � � .. . Signafur , . . . . . - � TOTAL FEE x . . - . . � .. . " _. � . . � .. _.. . . .rt• O •:6..{� s .... .. . .. . �. . . . �: Plart check applimrtt . _ . . .. . � :.��� . . . -SINGtF FAMILY � . . . . . . .. . . _ . . _. : � . . .. � ...�. I • �I G CI�Cl '. �; � HQME OYJNER•BUiLDER DKLARATION � Name . - . � � : {' eby offirm tfiat+am exempt#rnm Ehe CorFrracta`s LFcense : . _. r• !� �j G y.-s S� for_thafstf#cxring_renann-j5sctcaa-l4;ft.S.-Bus'saesaar+� _= Addr_ass . ..� . ,:, � �._.,. . �,Y._—'-` ._ .., �_ �- ,�. ., .. . ,,,.._ .::.- , �:'i Frofessiom�tnde}:� .'. . . . . .�. Grp � - .� - - � . -7eL�hb.- - � . . �� � . -- u��9��J� -. -3 . � . � . . �. �- .� -� : . . .. . - � .. - , . ... . . . - - . . . # � I,os owner of the property,wi�t do the work�an�F the . . . � . . . � � � struchire is nof intended or offered for sale�(Sece�an � � �� - - � 7044,-6usiness and Professians Code). .. - - � - � - - - � � - .� - � � .. � GQNSTRUGTl9N tENDiNG AGENCY � �_ � - � - . . . .- . . . . , �� � . .. � ` � f hereby affirm that tfiere is a cansmrcrian lending agency for - . . � . � � ... . . -.. ... _. � - � . . -- ` � thE Fteclnrmance.of fhe�[.�ork.fPr_.which lhis.perrtiei is iss�ed � .- ' - . . " � ' � ' . . - � _. �. . � (Sec.3097,Civ.G}. - Esnde�'s Nnme - � . . . . . . � ._ .. . � . - . . -.-- � - . � _ . . _ . � � tender's Address . �. �. . . � - �. . � - � . . � _ � � � � -. � .. - �{ I certify that i hnve read tFis opptrcaiion and state thol ihe - - . � . . � . � . � obove in#amatFon'rs earract..4agree te cflmply with nli County . . .�.-, .__.. � � ordinoryces aissf-State I¢wsrgg"�IattngPtumbing��n�t hereby-.._. -._ . - - . . � . . . , � � aud�nrize iepreseatati�cs of.)l�is Cosrnry�to enter vpon fhe -.. _.. � ..- ... . . . .. - � . .. . . . . � abovs-mentiQned pr�pe _ _rrrspecrion p�rrposes SEE REYERSE fQR EXPLANATORY LANGUAGE . � � l'J 'C3� _ ! -.i re of ermiltee. . . -� Dote .- ._ . ... . . . ... _. . - . . . . . - . -. � : iE _ .. . . .. . . �. .. - .. � . . . . 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