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HomeMy WebLinkAbout1221A (6) _ 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� . . }���..f 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 - . _.. _ . . - . _ . - . . . - . � . ..� , � . . � , 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� - . . _-_:.._._ . -- � . � � "��� � - . . - � . . � � . � � � . . .. � . � � � � - � � .� � r � _. • �; . �, �._c o o s ro ^I�' N L S � �s� � •N o a� a ° Q� � c c L �n u N �.. p ;�A� �a Y O � 0"O fl o . � � ; °o,,-C .oa „ o v,ati„m,: m � o - Qo � �ms.. s v .� �� •�t �Q �-�'p � coc�C ° .n > L�p� d.°cE� o > y ' . 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