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Home My WebLink About0776A � woeKeRs�connv�NSATioNoeciAunrioN ' /4PPL�CATION FOR PLUMBING PERMIT ;{� I hereby offirm that I have a tertificate of tonsent lo self in- �A�jA�4i8� sure,or a certificote of Workers'Compensorion Insurance,ora CE B77(REV.8i86� � I � �cerli(ied copy Ihereof(Sea�3800,La6.C.) �� , . . � - � , Pbl�cy No.j3y�QQ5p(�,ZQe@,�yN4'rjnNrarnF COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS � Cartified copy is hereby furnished. � , ZS . - � � . ZS�S ipR A7PlICANT TO FILL IN(PRINT OR TYPE) BU�LDiNG n CernRed copy�s tiled wfth the couniy building�nspection ADDRE55 Q7 0 TH WYNNE OOA DRIVE ��( deportment. Nl1MBER FIXTURE OR ITEM @ FEE ��q�ITY . Date�-1-RR Applimntj�$j.J P7_iTMRTNG WATER fIOSET(TO!LET) NEAREST ' CERTIFICATE OF EXEMPTION FROM WORKER$' BATH TUB fR055 ST. � COMPENSATION INSURANCE SNOWER� OWNER . ; (This��clion naed nof ba complm�d if rha work involvod by ��i fh�parmll l�ior on�hundred dollen(5100)or less.) � IAVATORY ADDRE55 I ce�tify thaf in the performance o(ihe work for which this per- S1NK � � - mif is issoed,I sholl not employ any person in ony manne�so � CITY TEI.NO." - os to become subjecf fo the Wo�keri Compenwlion Lows. DISHWASHER � ' � � . . . . CONTRACTOR Dole Applicont CLOTHES WASHER qDDRESS � � �ICE TO APPIICANT:If,aFter moking ihis Ce�liFim�e of Ex- SWIMMING POOI RECEVTOR �ion,you shoold become subjetl�o the Workers'Compen- Ciiv � 7EL NO. �sation provisians o1 the Labor Code,yau must forlhwi�h comp- �AWN SPRINKLER SYSTEM ly with such provisions or this permii shall be deemed revok= STAiE �K. BfJ. • � WATER HEATER LICENSE NO. - ClASS - � LICENSED CONTRACTORS DECLARATION D�SieiCi PROCESSeD B 1 hereby offirm�hof I om li[ensed under provisions of Chapter GAS SVSTEM OUilETS / C7 9�commencing with Sec�ivn 7000)of Division 3 of fhe Business � OU1tET5 OVEq � � ond Professions Code,and my license is in full force and e(• 5 a�R SvSiEht FINAL �/ VA IDATION p�", Sect. . � , - DATE v� �'�f � p , License Number 1}��af� Lic.Closs�_-,� . . U F�NAt Contractor NEW PLUMBING pa�e 8-31-88 BY u.� O f- � I am e:empt under Sec. �� . `�7 7'6� w 8.8P.C.(or this reason ° a Plan check fee , �� '" z � � Dote: . �p�UM61NG PERMIT ISSUING FEE$ I • � G S.C O -� Signo�ure � TOTAL FEE ' ' � �"'v.�i u . ' SINGLE F:.l.SILY � . HOME OWNER-BUIIDER DECIARATION P�Q�check applitant O�.� O-C3�, I hereby oHirm that I am exempt from 1he CaMroctor's License Name � - � � � � ��for the foilowtng reason(Section 703I.5,Business and � � � � ssions Code): Address � I,as owner of�he property,will do the work and Ihe �'�Y - � � iel.No. � � � � shocture is no�intended or oitered ior sale(Section 7044, . , Business and Professions Code). � , - � -" CONSTRUCTION LENDING AGENCY . - � . - I hereby affirm Ihof there is a consnuction lending ogency for . � � � �h0 performance of the work for which ihis permit is issued . - . . � � ' � (Sec.3097.Civ.C.). . . . Lendei s Nome � Lender's Address . � � I cartify tho�I have read this applicoiion ond s�aie�hat the - � � . - ' � � o6ove information is correct I agree lo comply with oll County , _ � ordinonces and Stale laws regulating Plumbing,and he�ehy -' � � � -- . . . outhorize represenratives of ihis County�o emer upon the �� ' � �a e•me oned property for inspec�i pwpose. , � � - � . . _ . , ��r SEE REVERSE FOR EXPLANATORY LANGUAGE Si9nalure of Perminee Dafe ; ' � . . T C � � 2 L) G) 37 C Do � D � O D D O z y C n r N � -i (!i N � m m� r � m � n ^' .�-� = 7° n y� n � z .-� z v Nr v . . �D , p �' � ~ GI C n � . 77� 2 T S�rt p � O � ' � � C D � Z O � . . � . ' � m m , G� � m rt� y 70 ' .. - v Z ." �J '�D - � � i C� e � � O ' � � m � �� a Z Z ^' N � m A � N - . � $ . , v� , � . .. � • _ ' • • .� ' � c � m Z . � . -o m ' . -n-i O � , � - � Z O � m • N � ' 0 Q � Q1 m »�o $�•�o�n� �"w �w y��v, � z�o`� _ . � m �° . � em � ° `��'ay � o ��' ^�,.��"'u,•o��m� o�� m . - m O m C . � o �� r�c rnatno� � ��u��vmi�� x . Qom c� oA-v^� Q� " " �VSamv� 6 O _ . n � pc ?movai� av; � °"� �Ap o'� m�ew m � . • � � 1 N � � f�D 0�� O�n�� 4� � �y � � � � Z , , .. � � � � �ci_.rC » �'�.�c.mmVt� ._�mya � Rt . : "` D � rnO�� wv'-�� wm`O $� �mnbi b� 21 . - , � r 7 C ' p �� U �t~ii� N -.Np ya , .. �. ' ; � v� � �c�m»�m�� 3 �y��oC�� i� um�i �_ C . � ' � -a Om �'mtn �nm � �� `c ^X �� y'� � y.0 � f �J � � C 70.0 fD �� ..�.� a .. O � ?�,�?�O� O � � �y� y ~y �.Q m m � O b . ' . , � • - � ' � b �7 �� 0U� "Om y � ��O �O �= x � � �qm �b�vy� � kwE� � � o 4°O� _ p . . . : ' $j�cc �� p�� D� ��in �� vai .��-� n , �� W� � C� y D� - � �.'��C b.?N N�� C D � . � �.. . . �� o �� a. '� $ ?ca'�mm 3 � �� • o �myo � �m mtr�, � v�i o°^aro � � ,- a ' - �" � �, m � ��^m __.�m . : ' , �� -� f �.� ?o �o ��.inm`� -1 � . . - - " ' �=�a� ya m � -`° u' O � y �D �S; oa � 'Z. � �o �� s? w � o � � . - . � , O� C� 1 � C � �� N < (A C D n �p� . . � . � . . �� O 3^O.^ � a y� n a� oi fp j O C �"p'� " �1 Q � N �p� � � , (� < ,'• 1, . . . .... � Q W � Q�...�l? � G�� O t,i> 4 cD W�i Vi N.