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HomeMy WebLinkAbout1370A (7) � 4LIQRKERS'COMPENSATIC7N DECLARATION . ���L���T��, C�� ���I��! � �`qA�lT /''} -I bereby,a(fi.roa}hat I ho�e a certificote of mnseni lo self '�76A667A . . � � � insuie,or a certif cate of Workers'Compensation insuronce, :CE 817(REV.8/86) � � �or a cernfied copy vhereof(Sec 3800,Lob.C.) . � . � COUNTY OP LOS AIdGELE�s �EPT. QF Pl18LfC�,WOF#KS , -P�o�icy No �.Compony � � � ` '' .Cerhfied copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT C7R?YPE) BUI�DING g' r�c '"' �' aCertified copy is fited wi4h!he caunty building inspec- A�DRESS, /�ldt-'f ��"� �� � �je�r lion department. NUMBER fIXTURE OR ITEM [� FEE ��AL�T,� I f,� ^�' i ,� 'z.� � �vaTeR aoser °1`:.� LP��`"., a�°�%,�L a�'1's:' L'a�_ Date� � Appikanf- � � __....�..,-._...__—_ _ NEAREST ,,,,/ / ,i � CERTIFICATE�OP EXEMPTION FROM VVORKERS BaTH?UB CROSS ST,�,.�Y �`,�.° yla��� , ; - COMPENSATION INSURANCE OWNER ,�%`�-°��� �'^`'`d ' _{This section naed nof ba cqmpieted if the sroork inrolvmd�y SHOWER " .�./�����'��✓t' �� �.3"�eL.'�a° � i -:tha permit is far ona Poundred dallan(5100)ar Imas.) ��A�� �{` LAVATORY �f ;,�,p�`� L:3- �j AOORES$%��r� ,� �-:1 certity ihat in the performan�e of the work for which+his �� E _permit is issued,�shall nof employ any person in any mannar SiNK CRY� y TEL N�p'�d% ��. :.�so as to become su6jecP ta the Workers'Campensatinn Laws. � �� DISNWASHER CONTRACTOR ' Date Applitant CLOTHES WASHER �ADDRESS ����d � � � �-NOTiCE T4 A?P�JCANT: Sf, afie+ moking this Certifico'a of SWIMMINGPOOIRKEP70R `�Ezempfion, you should become sobject ta fhe Wcrkers' Cl7Y TEL.MO. � � Compensotion prtiv�sions-o#the La�or Ccae,yo�musf forth- �AWNSPRINKLERSYSSE�L1 � . ^ wifh-�mmpiy �viP6 such-vrovisior+s-cr th'rs permit shall be � � STAiE tIC. _ - �deert4ed revOked. - WATER HEATER � � 110EN5E NO. ClA$S LICENSED CONTRACTORS DECLARATION � . 4 DISTRICT NO. PROCESSED 8V ° _ �I hereby aftirm that I em fic=nset?under provisions of Chapter 9 Ga55vSTEni�, OUTtETS �� � i �_�-(rommencing wi+h Section 79Wj of��vision 3��he 8usiness OU'1E750VF.R . .. � � ond Prefessians Ca�fe,ar.d my license is in§uli iorce and eifect. 5 PER SYSTf.M ! F1ryR� . . t„j�; . . 6ATE ��`$��Y'�� . E3 a � - �ticense Number— Lic.Class " - �� 3 - � - } FINAL - :� �. � ��Contractor Date BY . � � . � } '� 3 �� _ : ❑� -- . . . � �a` ` I pm exempt under Sec_w, �r , - 6.8P.C.for this reason � , 2.7 - � " Flan check fee � � , Qa�c: �_ � PLilh^,BING PERMl7 ISSUfNG FEF$ �x E.+� �. . , . .. � . Signature 7� - TOTAI PEE ,�F � m -_ � . � � � � - Pian aheck aoptimnt - � ;, e, 5 ti i ^-: � SI[JGLvFAMIIY - frgF. _ . j . HOME OWNER-8UIL6ER�ECLARATION Nome .'�"s "�;,f"�,�_�- ,��a,r'�=�_. _ .,;�� � ��I hereby aPfirm that I am exempf from the Contrador's License . e,ddress `�.�''''�'"' �� ' !'' < � - � 'law for ihe foliowing reason(Section 7031.5, Business and � �� ��- - °�- _�" a---�� � � �ProtessionsCade): City- ��/�g�'� - TeI.N�;�t�����,�V� -� ;� I,as owner of the properiy,..will do the wark and the - � strudure is not intended or offered for scfe (Section -� tl � � 7044,8usiness ond Professions Code}. \�, : <. �I -� CONSTRUCTiON LENDING AGENCY - Qi p I hereby affirm ihat thsre is a construction lending:ag�nty tor � � � �,�O� � � • - the peho m nce.of:the work for which this permit is�issoed s� � � � � � �� (5ec-�3097,Civ.�C.)� . . .. - �. � �, � . �� � � Lender's Name ...._....,....._._..� .....m_.._ .. �,f .. � lender's Address - r` I certiiy t{ipi I hove ead tfi+� plication ond state that the � � � pbove informotion' c cY.I q ree o comply with aIl Coonty . °� �� o�dinances cl. E�I S,reg�Aa ng Plombing,and hereby . . � � aurhorize re �tit�x'e�of thi/Coun�y to enter vpon the - � � obove-m h �+i3 �y io��nspection purposes. �� - � � � � '�, ,��.., e ���`.� �,� SEE REtlERS@ FOR EXPLA6JATORY Llatdt'sU�GE x $ig,'vr o rrrj±,}e� -6ate � . . . . r . � . . U C � '+3 V ?- Qi Z7 � i, C C, Q� .0 dj ui O ` C � L u O p,L � � . . . _ �„ � 0 3 o a� c, ;,ti � � c 4, z7 f._, � . r;- a3p. � � ��0,:.s C- o Y O � �.:� m �,=.0 c ;..� DII. -�.^J C G-� : fI 1 . . ;� . '? 5,-;-.'�.,�'e,M �' �,� .:� �-�� ,�,. � _ �,.. � ❑, '� C ,L 4 r � N� O :U y� QS � D O w . �'1 ' 3 ii�' � `� . 6 I o �:,c -o c � ��:� �.c_� 3 ,.,�w .� ;,� � �,s, t. - I � 3 �.:� �> k ,: � ; � �J --�,v �, .c�', � cu o:c �> ¢�.�-C '". .��.e q :� I- , �.- � .0 ;' � .c '!_ 'u v y . ..:tl r `T"�: s. C-E �-r O..� 0 cL i'�^.��J 1` � 1 . G a .. {_ N w..C �O.,L' a �� 4a;,[ b N ,'� � t- , � '='Qr 6 ].`.A i t ` � sf�, .ti �� , r �_ ,�. t1�••e _4 `1 O � C 'l �'d5 J D.'b � ): l. O i i f.' . . ,�, ' r , 1...' 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