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1221A
_ Go / � WORKERS'COMPENSAFION DECLARATION - ���������� �aii F`L��QI�G r GRtYi�� '?t11 I 1 hereby offirm thot-I have o certificate of consent to self 76Ab67A � � . . . __ . - -- {1 i insure,or Q tertifimte of Workers'Compensa�ion Inwrance, .I�E 817(REV.t�t81) : � � � . . - - � - - I 1 � � Ll � or a ceEtifies!copy ihereQf(Sec.3&4�:iQ6.C.y COUNtY OF LOS ANGELES BUILDIMG AND SAFETY ,,� ` �� � . Pokicy No. � � Company F��''C../�04�� . ._ . . � . - - .. �. . . - . . d.a� � I f�j._.Ce ' ed co{zY.u herehK#urnished.- ..�. . .. ... _ . . . . FOR APPIICANT TO fltl IN(PRINT OR TYPE� - BUILDING �� Certitied copy is filed wilh ihe county buitding iospec- RDORE55 - d� �� tion ClepartmeQnf'. - - � NU�N9FR � FIXTURE OR ITEM � r{{ � —$ _ ..�� �.� � ���n , � � DGte�:y V APF�i4ant � WAiE&QOSET � . . NEARf^sF 'f ..CERTlFICATE QF E7(EMPFION FRQM WORKERS`. �� gQ�NB � . � �-- ERdSS 5T. .l.tµO►}� �����- � '. �.. . COMPEM5ATf4N FNSURANCE - -. . . . . . . OWNER -. . "� . :` - . ..'. _ (Thls secEien rte�d nof be wmpt�d IE Nro reatk iarelvsd by SHOwFR . . . . . � a�41� . � � � �� . � rh.p..nrif is fo.ae�hund..d douun(Stoo}w►ess.}� � tavnroer � .. r,w�i. . . --� �ooaess . � Ql�'k t/�`�C•� �t cenify th�r-in the�perf6rmance of rhe�wak-for which this � . - .. . - . � . - -permif is iss�ed,I sha4t nof emptoy any person in any manner Z.. .- � �� . r- CtTY _ c,Q �f+��Q` TEL td0. . � � - � � w as to�become suhject ta the Worke�s'Campensotion Laws. p��WnSNEe - � � - � � -� � �� � � _ . - � ([t� �.�ty /� y �"" COMTRACTQfi DatC�"�S �"-1;�+,+litanl �..CT!1 QLn . CLOTHES WlSFfER . . . ..�y1 . . '�GE TO APPIICANT: lf,�after making�ihis Certificate of . �A�E� -_ �OL�-•��, .� .. ;pHon, ycu-.stwu3d 4ec9ace. 4�+bject tcs.th��.-1�rker�` �--.: . .,: St17MMNUG PIXk ftECEMOR. .;;-. _. ; .�;.� .,.�,.;_:. . . .- �. ��-. �.:- 1 er _ . _. . ..:_,._ _._.,..a....,....�.__..�u=� __��_.._.._..__�,.�a ...._..v,..m., . . � �mpensatton provisions af the LabarCode,Yau must forth � - � �TY � .. . T�.�. : � witi�-comply w"rfh svch provi5iorts pr fhis permit shpll he t+°,wP+SPRtNKLER5Y5TEM . �-SrA7E I' deemed rereked._._.- warHt r�,aT�rz ...- ticervSE nra. � �n� i R �� - � OGENSE6 CON7RACTORS DEC€ARATIQN-... * OtSiRfCi wp. . • . .. e�tOCESSEp Bv. - . �t Er�reby vfftrm fhCi f am licensed undgr prPy'rsiP�S of Ck[�pter.4: 4 � C,�SYSiEAA ..-.�IXAlETS� � .�� . . t� - - .�� (€ommeFuir�g�welh Sectoan�7QOQj of Oivision 3 of rhe 8ustness� - 4UFCEi50VER � t'�� � � �'� � � and Professtt�ns Gode,qn�:lmy ticensa�s�u,fuik f�c�o�-e##eU. ,.. .--..5 uEa SrSi� . . } ��s m HNAt�� F U� YA QA'E[�N Q � . . 1ice�eNumlaer�. lic Class ....�- . .:� , .,..�. . . ..... � �� ���L� . LJ �.y� ' - � FHVAL� . . ... - p,s .p . . .ConMacror ....j 1��1e���--`�Onte--�^�~_�-___ .�. � . . BY . .. . � .p Q.. . . . . . . . � . - .. . � . . . . ~ g I am.ezempt under Sec. � -- . . . . . �� � . 8.8P.C.for ihis remsan_- .. . . �. . . � � � � Plan check fee Z - [?ate; -�- . .-. . . . .. . ..' . . . . .. . �-� PLUMB#NG PERMfF tSSU1RtG FEE� - � .-. .. .- . � . �� . Signature - . � � E rorai.�€E �� �C? �t �f i �t ! _� .. . . . - Plan check applimnt� _ . .. . .. . . .._ . . . �� . -�.:- .� �:. . . - .. StNGt€PAMILY � . - - - . . . . . � - K.a�"s a e � -rj ._.{ j . HOME OWNER-BUICDER-6EClARA7tON � Name � - � - - - � �� �bp affirm tFmt I em exempk from the CortKoctor's Licansa � - t +.k t1��,t�„ �����i . - .,_-_ . � ._.» � -.m.- :_...,..-.....,-.._.,..:� ...,»� .::_. Addres�-:._ �. _.,_.,_.,... _..,.,......, �-- L4. rof-thefaliawingreasan��{Sectian�7A3#.3�Svs.ricssar+d - _ .-, . . ',:, _� -:. ,._ , �.;,_ .,-.--. �Ta = :- .. .. .:.. . � -Prafeuions Code).-.: _ . _. .- � � - - • " � �,u,�U u� - : �.,�. D._. _ _.: . . City_-_ -Tef.No. - �... - - - � . . � � I,as owner of the property,wili�do the work and the . . . . . � Q"�O�.,��c � . strucsu�e is nQt intended or Qffered£ar sa4e-(Settion� . - - _� . - . - � .. � �: ... �. 76d4,Bvsiness�v�d Profassions Code). � � � - �-- . � - . � . . - :� -; CONST&tlCFION LENQMG AGENCY . .. � . . �. - - . . - .. - .. . . - . . :. :` 4 hereby nHirm t4otihere is a consiruction fending ogency for �� -- �� . � _ � � � � � - - - . -. - � . . tke-performance of tiie w6rk for wfiitfi ffiis permifis�issued . --.--.. .._._._ . _ . . . . . . _ . , _ . ; - - - ESec.-9f147;Ci�-E.). - . . _ . . . . � . � . . - .� . - . . - _ �. . . ._.. . . .. - . ..._. - � . . . . . . . . . -� S � - Le�der's Name - . _.. _ . . - . _ . - . . . - . � . ..� .. . . . .� - . - j , I leoder's-Address�. . . � _ . .� _ . . . . . . .. . � .. . _ � F certify xFxif:I nave read this applimtion and state thai the � . -. � � -_ � . . . : . . - above information is correct 1 agree to comply with oll Counfy - - - - . . -� . ordinonces and Stnte Iaws regulating Plumb�ng,ond hereby - . .. _ _ � . � � . outhaize representatives of this Counry to enter upon the �-- .� � � . . . ���: - . -�� � � � � : above-merttia�ed properfy for inspect'rart porposes. - �� - � -� - .. . - . . ��� - � SEE REYERSE FOR EXPLANAFORY tANGUAGE �'-�-�5 Si n ra o Permittee � � -Dare� - . . _-_:.._._ . -- � . � � "��� � - . . - � . . � � . � � � . . .. � . � � � � - � � .� � y' ;� .. , � � . ..+--... � :�v`� . 'j _... ` . . . . �w:: '� . . � � A O'OL-O , - � . .. . V .T„ � C [n'" S .. . . � � O O v� 81 C C . . � = - .. . .. r C .L m 6 � �0 N O� Q � " . � ,. O O. N '� P� . . � � N� � p' 4� .�C 6.0 N .Ll 6.�Of�_� - � . . O.L ;O,p v C p . p , ..p'0 Gd m C �, N u�, m o m w a� s 3, m s o ��u a �°n ;r o r o wa y s �, � r y s �.. .. �o :o r N �v o s y�, c 3 y ,:�*' o-� O 1���" Q+ � G N � O.�O C `� C. ' O O � O C yil�O � p �'y . . � � . a o o m�o+.a o�m o O�s •%��'� � � � �'-�o j „ s o, .. y o0 0 °�0 �°u��v>` °' �?„ oy$i �� onm v�. o �Y °' r'.,- s O �E o °' �' s, �m £ �a� !Si'as amsms,�'" Ja �, �� � � Q o o y_�-�';�- ° m s Q °'o ° .Qp��'° N s,N s��° � + v � . . - . . � �' .a- 6 C } �E�G...O- C C, 6. Ol 6.���Q �'C O 3 p 0� "d h _ � . . G. m4 0� �, o�°y o m o 0 o s��`� c�••-�+os 'o � y U a .. - o °' �u r� m o� $. �°y �,_ o. +- E�. rn m � s n.+ r � o �' ., o � O ux �� �a� a-? o � E o a ° .� �V o E o y '=2'. E. � "" � � � p� Cy �„J .>'L � fl..d . ��.���p� Om� O � X���iU � � p o�' o `�' � m c� °s"o°0. ..:°yr% �`m�-Mo '°�"o E��'° . �' . � p � � .p t m O `'�u N � � .O m G u�'.o a ��u'�.t"�O O C'31 p.�� � � � �iM= � . 4 � 'U�y S G p y'�' ~ p0••m G�6L"��..O� n .TD p N'p�^M � o� E�'a � ' . �''E c °'c m a �n V s'"- ° p ��o 33 '_ . � a �Fy j p� y�•pY„S p.0 � O Cp.�p,�s�+' . . �n ` S'L p G G u O O r. U . . . � .�/� t� � � � �.��/1 „w . .. � .. m C N D. �.. ? �C,u . �^u d � m o tiT t �m � Z �` O � "M � '' .' � r 2 f�Y� � '. ... . ..... � ... -.., . 4l� - ,... a �Q �� � � 2 N ,ra � G �' x � o �� .d� �o � � , f ,, p d ,'" °y�.• O 0� � r„ �� .. t w ' ' . /�, • r . j � x - � � . �,� ��_.,- g � ° � � Y� �� � � � �. z3 � � � � , 4 � � a Q y °' � 7 ..--'�,,, � � � � � ��'~