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12_16_1989 - 2016 PEACEFULL HILLS RD
�i�s �: � �9 -' �WORKERS'COMPENSATIONDECLARATION � �APPLICATION FOR-PLU�� I � 6 g,p� � I hereby,aHirmyho�I have�a certifi�me of consent to self in- ���2'ADaw aiB7 � 5ure,ar o cer�lf�ttlt o(Workers'Compensation Insurance,or a CE 817(REV.�B/86) � - - � � � � S��M!\ ceitlRed copy ihereof(Sec:3800,lob:C.) � - V/-'t Policy No. Company L� /� - COUNTY OF LOS ANGELES DEPT.O B I R 5 ���Ce�tified copy is hereby furnished. � , , � . � � BuiLDiNG / � �� � -FOR APPIICANT TO FILL IN(PRINT OR TYPE) AODRE55 O��j � ���5 � �Certified copy is filed'with the county building inspection � � � department. . �- _ NUMBER FIXTURE OR I7EM @ FEE ��A��TY � . � � � � WATER CLOSET(TOILET)� - � ���/��� - Dofe� ' � � -ApplicaM � � - NEAREST. . � �� �' CERTIFICATE OF EXEMPTION FROM WORKERS' � eniH TUa. CROSS ST. - -, .;�,COMPENSATIONINSURANCE . � � � SHOwER � - - OWNER�. . - -- . (This wction need not 6e complated if fho work inra�wd 6y ,Hp,i� . - _ ihs Farm�l is for one hvedrsd dollan(S100J or Isss.)� �� � LnVntOrtr- � � � � nDDeEss � � � � � I certify thal in the performance�of the work tor which ihis per- . SiNK � � Ciiv -� - �� 7EL n10. � � - - mit is issoed,I sholl nof employ ony person in any monner so � , . osYo become sv6jett to Ihe Workeri Compensotion laws. � - DISHWASHER - . � � � . . . . , , . . CONTRACTOR �C ��`�� . . Doie .. . -APPIitOnt � . . � . . � CLOTHE5 WASHER A�DRESS � �lF-i- ' . NOTICE TO APPUCANT:I(,ofler moking ih s Certifimre of Ex• -- � Syy���NG POOL RECEPTOR � � � . emption;you should become sub�eU fo the Workeri Compen- CITv / TEL.N��,�� � solion provisions o/ihe Lobor Code,you musf forthwith comp- � �,qyyN SPRINKLER SvSTEM � � - �� � ly wifh soch provisions or this permi�shall be deemed revok- SinTE � � . . � ed. ' - � � , , �� WATER HFATER � LiCENSE NO � .% J CLASS � ��� � �� .UCENSED CONTRACTORS DECLARATION � . DiS7eiCs-qi0. . a20C D BY . . I hereby affirm thot 1 om litensed under provisions of Chapter G.45 SYSiEM OUTLETS � �—` 9(tommencing wi�h Sedion 7000)of Division 3 of ihe Business , OUTLE75 OVEk� � and Professions Code;and my license is in full force and ei- 5 PE SY TEM. � FINAL VALIDATION r fect. .� � �l - �/� . � � DATE ' �' � � ` p `,on ro or mber�,7 �3/`J��ic.Closs�> . . V �f �j[��� E/f/T- BY A� O . /' � �N'" " �, � Date "� . . . F. . � I om�exempt under Set. . ' � - ' _ W �- _ a e.aP.c,fo� ' �eoson plon check fee � _ , x � . PLUM0ING PERMIT ISSUING FEE 5 O � � � , .g i7 7,�A , �� $ignat e - . . . . . 70TAL FEE . . � � . � [� �. .•.. .5 SINGLE FAMILY � Plan check applicant � � OME OWNER-BUILDER DECLARATIO � � � - � . . ., . , I •��� 6.Jr O I her offirm tha�I om evempi from ihe Cantmcfoi s License.__. Name . ..-- --- . .-.._- ... -- - -- -- - -- - -�.-_. .'. --:. -�-_�'�-�� � �.�..�. .. Law or ihe following reason(Section 703L5,Businesr and - �� � - � � S O Professions Code): � - � Address � � . � �.��2�9-8 8 � : � � I,�os owner of the properry,will do the work ond Ihe City � . . ' Tel.No. � �. -� � � structure is no1 intended or ofiered for sale(Seclion 7044, . . . . � . . , . . . . . . . . Business ond Professions CodeJ. � . � � � � � - � � ,. �, � ��CONSTRUCTION IENDING AGENCY � � . � � � ' �' ' � . I hereby affirm Ihot Ihare is a construction lending agency fo� � � � , the periormance of the work,for which�his permit is issued - - �_ - ' _ � - � � - � - � � (Sec.3097,Civi C.)..� � �. � � , � . . ' - - Lender's Name � � . � � . Lender's Address � � � I certify that I have read this applicotion ond staie fhot ihe - - - -- � � ' -� , - - � � � � - a6ove informotion is correct.I agree ro mmply wi�h all Coumy - � � . ordinonces ond Stote lows regulatin Plumbing,and hereby � - � � � � � � � � ��� - , � - � � orize represenlat" s f ihis nty to enter opon the . . � . . - . ab ve•memione er r' ction pu�poses. � . : . . . . _ � . . .. �y � ; SEE REVERSE FOR EXPLANATORY LANGUAGE Signofure of ermitlee � a�e . - � - . � c � � a v .� � Y G �+ � 'D � p i �LZ y � m � 'q� y, Z C Y � ,. - DP C �" � a � m G� �L W O -. . � R N+ p 'q 9 ', m �t 'D' Tp �. z � �, � � jc � . -vr � � � p m �- • '. . . - O . T , N '77 N. ��`� ;+ . r � �� .. � � �; � ' � � . t � . , . � .� - 3 � • � ,� o '.� ' ,, i � � `, �. • '� � � g � � V v'. , � ... � � r .` �, ,. � , . . '� `1 ^ � . ^ Z e e �� .i � N — V i , � � �� .. � '� " i ,1 . .+- � J',A � iA.�'iy � �� F � ' O 1 u � Z � ��� � �� m O , ,'. , . , �, � 1,-,.. ' � . � y '. � . . - � 9 N _ Z � `� N � ; _ . � , , ' ��r, • . ' , ,�Otn.���.t�^nt�� m 73 ,,;�wy���� ���`� _ p' � � � � :: m ��o�cD�. ���N� �('���=�� 6� '��- . � O'O p. a Cjc'�Q fTON�C�� -p CA� �e Z ' . . ' , `, .r � � D'�O NO'.vi,.�� Np.Q a,� m .��� � .� . .. ' � ' u��om� tl��.n�,'m��°'"������mc�'r, .oR ?"„ C7 R° � � cm��NN-x•��' $�.�w .Q.'omm�—' � a ��� � � � �q K oc ^���.��a� : =��'o'�Sv;yvw�°D r _ , ' � , 'C� � : 3��,����mm� �g��o�._��3Sg� O , . ' ; � p U� v�.�'i� a.o5�N „L X ��y� ^' 7�ec� � -� � m� ao . � ' •+ C o �n.��m�i ��� � �ma'.c°v' aoo g v� O � � QO d�. 'f` D � ,w�Sc wv' Q �'�'vi�w u�co�i^'o' � 1 . in a' oc° �� c�5���°o� �y3a� w�ci�,io�m� C'� N :��..,a p� � xo y? �' ,.('' - . . - ,' .. (�fQ� wt�D7o���i�N'� 3�.a3 ....�������� �,� C7 C�����N�4 d ���p�.�� O .+K� . �' . 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