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R'ORKERS'COMPENSATION DBCLARATION ]6A66TA ^
I herehy aTfirm that � he�e a certiticate of�ons�,��0 9e�f =e.,,,=-ao, APPLICATION FOR PLUMBING PERMIT� i i
insure,or a certificate of Worke�s'Compensation Insurance,or .
a certified copy thereo'f'�(pSec.3800,/Lab.C�) COUNTY OF LOS ANGE LES BUI LDtNG AND SAFETY L�
Policy Na�l�'�Ompany��1�I '����
I � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN IPRINT OR TVPE) BUIIDING
ADORESS ��
�Certified copy is filed with e county building in ction NUMeER FIXTURE OR ITEM • FEE —
LOCAL�TY
WATER CLOSET
Date � �^ � ApP��cant NEqREST
BATH TU8 CROSS ST. �
CERTIF[CATE OF EXEMPTION FRObi WOR C RS' ,
COMPENSATION INSURANCE SHOWER OWNER � �
�AVATORY MAIL � }
(This section need not be completed if thc work imolved no�REss a
by the permit is for orte hu�td�d dollars (5100)oc leas.) SINK ' �
CITY TEI..NO, U
1 certify thnt in the performance of the work for w�hich this pISHWASHER � '
permit is issued,1 shall not employ any person in any manner CONTRACTOR � C 0
so as to become subject to the Workers'Compensution Laws. CLOTHES WASHER ADDRESS U
Date Applicant SWIMMWG POOL RECEPTOR �, a
NOTICF TO APPLICANi:If,after making this Certificate of CI7Y TEL.N . 3-��)� fn
Ezemption, you should become subject to the Wo7kers' LAWNSPHINKLERSYSTEM � STATE LIC. z
Compensation provisions of the Labor Code,you must forth- WATER HEATER LICENSE NO.� � CLA55�—"��
with comply with such provisions or this permit shatl be
deemed revoked. . � GAS SVSTEM OUTI.ETS DISTRICT NO. PROCESSE BY
LICENSEDCONTRACTORS DECLARATION OUTLETS OVER �!C �
I here6y affirm that I am licensed under provisions oP ChaPter 5 PER SVSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code,and my license is in full force and DATE
effect.
License Number�L �� � Lic.Class � �!`�� � 8Y
Contractor��jLL� Date ���� �� "
' � .l
� I am exempt from the licensing requirements es 1 am a Plan check fee
licensed architect or a tegistered professional engineer pLUM61NG PERMI7 ISSUING FEE$
acting in my professional capaciry (Section 7051, Bus- A
iness and Professions Code). TOTAL FEE � [�
Lic.or Reg.No. Date Plan check epplicant
�7 r
HOME OWNEK-BU[LDER DECLARATION Name . � p�:^1 a�`n .!:
[ hereby aff'vm that I am exempt from the Contractor's Add�B86 ' � �,,1 ,�v�.�
License Lnw far the fotlowing reason(Section 7031.5,Susi- City Tel.No.
_
ness and Professions Code): a , c^! ;'.,`:1.��...
� I,as owner of the property,am exclusively con[racting �,� � � _�.t
wiffi lirensed contractors to construct the project -�
(Section 7044,Business and Profesaions Code).
CONSTRUCTION LEND[NG AGENCY �
I hereby aftirm [hat there is e construction lending agency
for the performance of the work for which this permit is
iuned(See.3097,Civ.C.).
Emder's Ratrex
ECfIfYCf�TA'AHPCSS
I certify that [have read this application and s[ate that the �
above information is correc[.I agree to comply with atl County SEE REVERSE FOR EXPLANATORY LANGIIAGE �
ordin ces and State laws regWating Plumbing, and hereby
auth i e representatives of this County to enter upon the �
abov- entio rty f pection purposes.
��
Signxture af Pe mitte Date � ,
� � ��.� �. . . . . � •��..,.ir�.d.rY.�•.i=,a.�. �
��a�r�a� f�� _�aaa s i� ��a ' .ri
APPROVALS �ATE I�OR551GNATURE INSPECTU�'SNOTE��_ �� (j';;��]j'"`-�UII.DF.FIULCL:xEZI�.TI�':V
UNOER SLAB WORK
aOUGH PLUMBING _, 11Fer_by:;fiir.=;[k:v:I ara e�c�rtGo:r,tLeCo�tractor's
._—.....__.___ . � � L4�.An... 72w for th^-li':,iwitw rc:�ae(Stetieir 7031.5.
��AS wPinG � � __� i,.m�s�=s n:,.r P��olassier:c Ca-fri: Any ritY or coe�nzv
GAS VENT� ' � . tii:tc:'1 r."Ju^rt:9 C p:'r'l:!l! to coR9tr:tct, a1Fef, i8:pro�'C,
HOT WATER HEATEF ' '_ �._...�..._. 4..';::�ili::��,e.;r:j>;'�:'Q.:}�.cf�':f^t::rc',G�°ioY(o its ISsu¢si^e.
PLUP.C�Vh:G PIxTUAlB . , . . � �'., r,�T r :�.� p � c�.t:ir^t f�'satrie perrnit to f!!t a
-- ivj;�r<=�r ^;,atu�.�•uf tk._i h;� is lrc.rrerl perrstu.vat.m �he
A3 TE9T pro:i:i��r.r qf tJ:r Ca��rre:mrtr Lirerisa Law (Chcpter 9
UTILITYCO.NOTIFIED - — --' (<'r�t�f:'.;";•.:�:�,- i�:it.'' S�_'fl14>". 7A?f1J Of/SiVtSsr:N 3 oflflP
— :�:�ci�.:e�_� c:.,i �3r,f,-srioa: Cede/ or that 1�e is exe�npt
� fr.r�.f.,. � :f tl•r Fs�ar fo:th.:al+ �erl exenaptirut.A�ry
FINt+� ✓A�s� [Ma� �iRO�at �� inf:_-,:;.�, c.,cix�r. iC31 5 bYQ+Y�F'llcaei foro pen;ur
-- _ srbj^;:c tl:.,ar�..rieo-;:z!;�a cii�i(pc�tr:'1y of?tot rnore tftari
, .__ Jli'L):;;�`�"�Fi.14�'J.'�B'`5�✓�,SOJ�.:
�fVDWTRIAL , p i,�s D�vr.Cc Of t!ve pSo�seTiy w�il c7o tMe N'U[k,altd
AS#ffi Ad#R(3VAL� ' ' . . ' —
c:�=tructu:i�m�,ir,tcr.-Jed or ufi'r�cd fnr s.=1c.
_ , � � ' lS��c. iO-;:.', B:�s:..�ss m.d PrrzJeccinus Cude: Tlie Con-
, � b�:e;r�-'r Lic��;s� fcw: d�+�s �vnt a��;:y to a�� owr�cr of
� � ' ,_—'__ ^. / c.;,;Yt �.P�G.�t!'. c:ir;;;�r'ores�k.rrrn:,c:+d w�J:o dae.r
. . .. � � . sur}r i,orl. 1:ir�;rl,` �s-cr:.?er+ tl::rt sac1��ir:proverxea:s
� . . . � � . � __ � mr �vox i�uext(:d or o11�:'�"�for safe. If� Irou-ecer� IPr°
'
1..��i•.pir.^ ¢r i:r,n.¢re:���'rnt is so't3 wit}:��+ o,ie yc�er of
- . . ____�.___._�. _ c:�rr�r:ic:i,^�a, tire ovntcr�t,.�!i!�r N�il! 1+,�:•r tt:e Lurderr
- . . of ;rz�vi�.y tk^t ir: Cid �rot biatfa o;ir�r�e for the
— �,tr;r,;�qrs�Iz.J
S r^:m e�::^r.,ri r,r..lrr&c. ,
.li t^s`'.r.for tAsi,se:r•c;t—
�_____�.__—_—_--- G,�t:___----- —
� ' - , �— _ �!`5'��'Sl�._�� ___
� � �IN90ECTOR'S NOTES � �