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HomeMy WebLinkAbout0866A WORKERS COMPENSAflON DECIARATION t �{'P��e..pS i�Oi= �vGL P�fiiYi�di�iV ��n�Y��� �� � 1 here6y affirm thoi 1 have a certifimte af con o s ��q667q � insure,or o tertificate of Workers Compensalio 5 n a CE 7(REV.�0/Hl) . or o certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ' ��Y n,o. zo1916 co�,��„ sclF 4465 Cerlified copy is hereby furnished. BUIL�ING � fOR APPUCANT TO Flll W(PfiINT OR TVPE) AD�RESS 823 Windwood Cerfified copy is filed wifh the county b�ilding inspeo NUMBER FIXTURE OR tTEM Q� FEE tion department LOCALAY WaZnut B� Tnatall �NATERClOSET NEAREST Dnte �-��A� ApptiSon�'.aE21P.� • GERTIFICATE OF EXEMi?ION FROM WORKERS' BntH iUB . cROSs 57. " CQAAPENSATlON INSURANCE OW�R ..aTOSe I�k.'�.4"�`�7.i�CI�$- .. SHOWER - _ . _.-__. _- ___...- (ThN aectioe naad-nat be comP���16Q week is�eol+eod by .. nrait ..,. ._ T - . 1he pormll ia fnr ono hundrad doliws(S100)or Iocs.} LAYATORY ADDRF55 23 � 1 certify that in the performonca of ihe work for whicb this _ . . � � �- y.�� � - permit is issued,I shoA not employ any person in ony monner � + ��tt � 'T�S.•t� 45��� � � so as to bacome subject m the Workers'Compensation Lows. _ . �' �� � - _ ��+ ,� .. : con,Ta�croR�eneral--Instaillation Ca. (f - --� -..__ _ .- ( Dale Opp�i[anf � � - - - CIOIHESWASHE f AODRESS - ` `� NOTICE TO APPLICANT: if, after making ih�s Certificate of, ._... .__. .._. . . .. . .._.E55S.--Idest.-32ud.��-�- _ - - - --� _... . . . . � Exempiion, ycu-shoold-become�su6}ect•b���e-�NEorkers' � �G�RECFP -- � �� � Compensarionp.ovia�onc.of,rhelaborGoda,,rvvmustEorth- . uwNsvaitv�tFesvs�t _ atr LaS AYSgBZes �e� "0753 ��4Z . � �� wlth comply with such prowsrgns.or th�a permit.shaH 6e - .._ � � - _.., _ �.� � . .. .._._ ... deemedrevoked. "."_. '.;�„ �_..�.�-._.. . , .., . � . �. WA7ERHfAFER..- . .__.- _.. :. ...� �Q.. LIEiTN5EN0... �ci ��1- ! ftA. .•C`�BY . ' � . IICENSED COPtiRnC.CRS DECtARATtON __ _ �t57BtCi rn ... . Ss�o � i here6y o$rzm that I dm bcensed under prnveslons o4-Chapter 4 � �AS Sv57EM � WTLfTS 2 ' (commencing wifh Se[tion 70W}of Division 3 of lhe.6�siness . ._ .__ QUIIECS�VER . - -- - _-_ . �^ � and Professions Code.nnd my 1¢ense+s in f�ii face.ond eifaU. 5 tER 5`lStFAn � - ._ . .. _ FlNAL--,-- - _- .-.=-VALIDATION--� --.... � � � . :.,.-..-. _ _._. . . .. ._. _. . . .- DATE _�':. FJ�, e: . .. .. __:..- . . License Number 3-5���g lK.C{oss � C36 - � ... � . . . � - - - � � � .. ,_ � . . . ��. .. - � - - ftNAL � , . . . ..-. d � ConKaCtOr � Q Prav�n .�K 4�55 . ._ __ ._ _ . _.. $Y.. � -. � . - �Ly i ❑ 1 om exempl under Sec.... . . . : . � �� . . � -_�. .. _ . . - :v_ .... _. _ .: .. . � - N _. � B.&P.�.for this reoson . - ' Pla��ERteC�fee � - .-. , :: �.�.-'�.�-- .- --`-- - . _ _.� � . . . . i - . .. -..: . _ �-.'.. .-.-.. . . - . � ..... _.... . . - _ _.....__...._..patm_-. _ ... .__.. .. � .. _ . _iQ �'J0� � � _ ... __.. .. ._-.- . --- - --_ �.._....-...PEUM8INGP�AMEI-.tS5t37tJGFFEt� . . �.:. -..._ ... _ ...... . .. . ..._...� � . ___.._._ . _'-"--. . . } _.-._ ... _ . . �Signmure � .. _ . . . . . . ..: .. ! � roTwi FEe _. 1.6 50 , � . � - Pkan check appfimnr � � � - � � - ' - - � _ �-�'��'f,u� i SINGIE FAMILY � � � � t a ` 1 HOME OWNER-BUIL�ER DECLARATION Nome - " ° .°'' - � I bereby affirm that I am ezempf from the Contrac?or's Litense . ���'���� � ' � "' "' ' , qtldtesy . ... , . .., .-. . .. . :�_ � ._ . ��'. . � t:e�c,. : :. . i Law for the following reason(Secflon 7031.5, Busfness and _. „ � , � �,� - P.efeasions Code): ' Gty . . .. - � Tel.No. . . � „ . . �. ....-. � ❑ 1,as owner of rhe properry,will do the work and�he •., ' r stracture is not in�ended or offered for sale(Sectioa � _ .� U!.c:-�% , 7444,Bwiness and Professions Code}. CONSTRUCTION LENDING AGENCY f hareby affirm that fhere is p construction lending agenty for - � � � � � � � � j the performance of the work for which ihis permit is issued (Sec.3097,Civ.C.�. . . . � . -_. � .. - .... _ . ! Lendefs Name . � Lende_s Address � 9 I certify Shot I have reod�his application and sbte<hat the � � a6ove informa�ion is correct.I ogree to comply wi�h all Co�nty ordiaancea ond Siate laws regulating Plum6ing,ond hereby . - i aufhorize represeniatives of this County lo enter upon ihe � - # obove-menKoned prop o inspection purposes. SEE RE4ERSE FCR EXPkANATORY LANGUAGE � . I�ilCi /d ���V __.... .. ........-:._.... .. ._ . .. _. ...... .-. I $ignot6re of Permitt Date � ��� �,.+� r��i� . , �,� .. �� o o�� . , . , V ` ? � � � . � '_ m � � O N.d G C�Z . 1, " � . . . � . N� yN p a� O �,�. � y���'O ... O � ' . ' , 0 p_ y (Fj �. 0 N ��� . ' . 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