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WORKERS'COMPENSA710N DE�LARATION ,qpp�.{CATIafi1 �OR PLUA�AB1i�G PERii�IT �
;
i here6y,offirm thoi i have o certificate of consen�ro seif 78A867A � ,
insuro,or a cartifitote of Workeri Compenwtion Insvrante, CE 8f7(REV.8/86} . 3
cr a cerrified copy ihereof�Sec.3�ab.C.) i
P❑ol�cy��_company C�UNTY OF LOS ANGELES DEPT. OF RUBLIC WORKS �
Certified topy ia heroby furnisF+ed� !
� FOR AP�IiCANT TO FILL IN(PRINT OR TYVE) B���w� 3 i
Certitied mpy ia filed with the caunty building inapet- /�� k
tion d�eporlme� NUMBER FIMUREOR ITEM � FEE �
3 i ����
WATER CtOSET ;
Dale Apppqant NEAREST
CERTIFICATE OF EXEMPTIQN FROM WORKERS' BATH TUB CRO55 ST. ;
COMPENSATION WSURANCE OWNER 4
(Th1s s�ctlon nwd nof In cornplNrd if Ih��rork inrolv�d by �OWER
flw parmtf Is for ona 6uedrwl do{(ars(=100)a ks�.} wvaiOkv ���
I certify fhal in the performance of the work fo/which this ADORESS
permit is issued,1 shall not employ any penon in any monner 51NK p7y �,ryp, j
so m�0 6amme cub�ecf to the Workers'Compensotion Lows. `
DISHWASHER CONTRACTOR !
�IR � ��1(`�'••^�� CtOTHE5WA5HER '
ADDRE55 �
; :E TO APPIfCANT: If, aftar rrwking Ehic Certifiwle of ' D• �
' �ption. You shoutd become wbjecl ro��1he Wakrs, Sw�MMING9�.RECEPTOR . c�n 7EL.NO. �
Compensafion p�avisions of the lobor Code,yov mvsi forth- �e,WN SPRINKLER SYSTEM -
wilh comply wilh such proviaions or this permit shpll ba STqTE :
IIC.
deemed revoked. WATER HEATER LICENSE NO. �Q CLAcS �" < <
410ENSED COMTRACTORS DECLARATION DISTRKf NO. VROCESSED BV �
1 hereby aff'rcm rhat t am(icemed�nder provisio�n of ChapFer 9 GAS SYSTEnt Ot}TlEiS -
(commencing wi+h Sectivn 700D)-ot Division 3 af the Bnsiness purtErSovER � g
and Proiessiona Code,ard my license is in f�ll force and effecf. 5 PER SYSTEM
� DA EL r � VALIOATION v :
t�,�
licanse N�mber 3 o q A�3 �ic.Clau � 2' �l�C � �
���� L FINAL O i
Coniractor�l�.k. AT•^r�Dote '� 'Q BY / F" `
� � � C
{om exempt under Sec. pw, %
''zTLl4.C11 y '
B.6P.C.for ihis reason z �
Plan check fee ;;.. . . .�
DaFe: :
PLUMBING PERMIT ISSUING FEE$ �Q � � i �G�� 3
Sigrwture
TOTALfEE
r n �=.. .,., i
Plan eheck applteam e ,� r
SINGLE FAMILY ����� —R 7 {
�' HOME OWNER-BUItDER OEGkARAT1pN +� Nome �
� i�Y ,�y oEfirm Nwt f aen�xanpt frain t!�Conhaelols Ltcams . . . . .. -:...,:.�_-..-.,
,. . ..: ,. � � :„ . . . � ......��:::... .................. . .. .�:...
' 16w for�the folbwing rcason(Sectton 7031.5,Business ond Addross � � � �
Profeuions Cvde�: �iy Tel.No.
❑ I,as owner of the propeny,.wil4 do the work ond Ihe
sMucfuro is not inSended or oHered for sale(Saction � j
70aa,Bufiness ond Professions Code). �
�ONSTRUCTION LENDING AGENCY
I here6y offirm that there is o conaNucl'ron lending agency for ;
the performance of the work for hith this permit is issued
(Sec.3097,Civ.C.�. �
i
Lender's Nome
!
lender'c Address
I certify ihat I have read this apptication and state that the � `•
above infwmetion ia correct.I ogree ro comply wirh all County �
ordinances and Siate Icws regularing Plumbing,and hereby
ou+horiza rapreaentatives of this County ta entar upon the
o ve-men�ioned propeny for in�4�pec�ion purposes. SEE REVERSE FOR EXPLANATORY tANGUAGE �
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