HomeMy WebLinkAbout1697A , ��ORKER$'COM.PE'�SATION DECLARATI'JN APPLICATION FOR PLUMBING PERMIT ���2�' � ' I her�by aHirm th�1 I hovrt a rerii(imre a(consent la ulf �h,.,y��p \ . \ � p� � �� �.�,��,,(^� \ \ � insurr.,or a ceriificaie of Workers'Cnmpe�sa�ion Insuronce, CF BI7(REV.70i81} 0.� c�a ce�id��d cepY�herrof(Sec.9AW,Loh.C.) COUNTY OF LOS ANGELES BUILDING AND SAfETY �cy No SL1�"�W.S�_Cemponv�l:.�C]� ... . Cerl�f�ad toAy is heraby fu��Isf�ed. FCR fiFPIICAhT TO F'tL IN(PPINi O4 TYPE) !'URD'N`^. ��Ceriihed copy�s filed wuh iho coor,iy bu��d+ng inspec- f.D.^.RESS ��o��pr�.�mF � NUMdf7 FI%TURE021iF.M (r" FFE , �T' (� lOCaIITY Da�e��Ap,licanl� 1�P1�JOhS WA7CR CIOSFT ��4, � � fvEn4(ST CERTIlICATE OF EXCMPTION FROM WORKERS' BA1H iUd CRO55 St.L bh 1 '�G COMPENSATION INSURANCE C'7JNF � � � � (Thi��xflon ne�d no�ba compl�bd if thr work Inrolr�d 6y � �u�`�C4 " - `�A!l Ih�parmit is fo�ono Aundrsd dollors(5100)or I��s.) L�VaiCRY 11CDRF55 _ "' 1 ceriify ihol in rh.e porfermonce ef the work for wh�ch ihi, � pe�mH is issued,I shail not employ ony ppraon in ony monnpr Si�:K CIivC $��\A e SL+ /�_ . �12'2 � so os ro become subject lo Ihe Workers'Compensm�on Iaws. \'\ J Lh^ ^-�G. 'J 1 DISH'NAS14R � -� �OtiTRAC10R r� � `',�S `�� � L � r Dole AFlPliconl 1 CLOiHf5WA5HER � NOTICE i0 APPLICANT: If, nfier ma4ing �his Certilitate oi �DDaFSS� � yemp�ion, you should become subject ta ihr Workni •`+f'�!�.'N��LR[CFP?OR GT � f� pr' p t �ompenw�ion provisinns oF Ihe Lnhar Code,ycu mus7 fonh- ��y,�N�oai�;v,irosycrr,y. ` V � ` n I�1��L'11��"fiL.7Q wnh comply wuh svch provisions or Ihis permil shnll br. SfaTE 1�G �' deemed revoked. WnTFR HFATFR I ICENSE NO L�� C1A55 3 LICENSED CON7RACTORS DECLARATION '— rnSrRiCt r�o °vc SSED 5r I hereby nH�rm tFo�I om licensed under pro��s�ons of Chopeer 9 CAS SYSTEM OUTIETS ,� �� (commencing with$ect�en 7000)cf Divis�on 9 of fhe B�s�ness Uu�tEi50veR end Pro!ess�ons Cafe,and my I�cense is in full(orce a^d r.Hect. 5 vF4 SvSiFm FINAL VALIDATION (��� � DATE 5�Z'_v O License N�mber�'�110�� l�c.Class� Q �� � _��� FINAL U Con�roc�ar R�n.�e��-S�� o����G� AY �µi Lv ❑ � I am exempf urder Sec. B.RP.C.(cr Ihis reoscn , W Plon check fee p„• I �ate: p�UM3!NG PER.MIT ISSUING FEE 5 Z j Signo'ure ^ I TOTAL FEE 1 � SINGLF FAMILY P�a^�heck opplicani . HOME OV4'NER-BUILDER DECLARATION Nome '�+e.re6y offlrm thot I�m�.Pmpi frem the Con�rnctoi s ticensr. qddress �y i.. �tie(..ii., y ".,,. �c......,r 70�:.... ��.�,��e ond rieiessions Code).�^ Ciiy Tel.No. ❑ I,os owrer cf!!+r,prcperfy,w�ll do rhr.work�n�{�hrt :.1 ������� strodure is not if1�P�(�P�cr oifere.d for sole(Section ► � 70a4,Bus�ness a�d P�ofess�ons Code). �, n . e e j CONSTRUCTION LENDING AGEPJCY I heraby nNirm!hni!herr is a cc�strutfion lendinq oqe�cy ior ,, s e o .j ihe performon:e of ihe wcrk fr.r which this pe�mi�is issue.d (Snc.3097.Civ.C.). � ° � � ?;;� lender's Nnme " " � I t' ::!1�_� LPndei s Address L i+CC—C: I cartily rhot i hove,rer.d�h�s orn��coi�o�o�d s�ote iho�!hr ► o6ove Inic��^oKon is cerecl I og•r.=to con+ply wl•h oll Covnty crdinnnces and 5'o�e laws regulartng Pl�mh�np,c�d Fereby ou!hcrizn reF�eientn•ives cl this Ccuniy ro emer upen Ihc chove�me��ion=d prc(:crly fcr insprct:on purpeses. SEE REVERSE FOR EXPLANATORY IANGUAGE $-?_G,-g� Sign� re of rr��•e� � Dr.tc c Z� � �; � " U �+ �` ij 'N i � �= : t. " 1+ �" Z? �`� 'r I S, =� "' y ,L ' c w r• ';.c�.i � '{ �� ! ^ 4� , , O �mu; S., p �... _ ,f r� ); 3.'�� 7 a �� (,') T �Y� V � � } � �. �� \ C) ��' =� u' S. V i ^` ' �{`' w � . V � '�� � �� �� m : c � �� ~ h \ �t.i l\ \ C` . � 1 c:,`,�`� C .. ^� ���,� �`` ;, "'� ?• . �•�� � � � � \� �� - �• r. ? O � F N � �� N n �� 1 � � � 1 O � G c�i� . ", O a N � - � � � \ ` ,� \ � � \ O \ ` O .++ \ u• � � -+ c'`r S �y o r, �, � o � v`o �. c � ^ e� ^ G O O r=7.� O, nV D n .. �. :s ��...�� ,� o n � °.'" n �, �. O in � n ? c , 0 3µo oN�°,^ �N o "'�, o �o �`� n��`'7� �. ±,r2� �p � r,,a� Q„t p �� �, ��„� � G „ 7 9 (7 n O(��N Q O r, N N i O �f' f V 9 � .0� � d?C 7 '�'� N o^.�C'-cl'�;V n ^^ �' W ?'t� 1 �.C p N f. G \ O � � x O C" 0 O N O!'W N � :. %�O"'`Q c N 1^ no O C'O J C1 O o n-�o � :i p � � _.x �, �-� � �,�r ' ci 3 t�� a o - n � .� 'c�+ o � � � N^0 3 0'�r � o ,�j:G `^ � f c �� � °c�r� a '�' c =�.,,o.p ro 4 � i� ; - % w n�n � o ', e.,,t� 3 'n No- W n c'''G c`e � �o�' � ' ' 3 °� ° o o'�,? ' � .��% � � £, v MQ `,t? oc ro _-o � � o n � ?, "' :.: o > ^' � .� ::^ 'o �� n u+. � s�� o ='v°,-�•o .o '° � c o � ' ^. � 3 ' � �n n � � t4 ' �v N �, 3 .nsG, a=o _ 3 � ' C) � S' . . W co s.c v.t c3. � 3 �.e ,�. '� '�� � � o' "L c c m -r�'� o N � 4 0 � "�� o'' Q n o � n ' m.[, O -� fl (1 Si � �'G a � M C � f: O p n .. ' ° o+o<� yo c^o �n o p p3 N��n ��, ,-^ �J, „� 3 (1 't .. . O,n p �� �[ > C'. < v n „ <=j �` �`�n O � W(U '"'O O ?� ..��� � ? � 'C c:. p �.�.0 `" �'3 o s f --G cn� a -. � u' . � Q��n = �-~n ^ � ° 2ii� : �, "• � N � .� . �. � n G '^ n 0� ? 0.� G N N S�: �/ O GC-. v 'U� .. r. : � `" T? ' � G � �'y � . q 1.^. � n G T� V? G n . Y'�.