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WORKERS'COMPENSASIONDECLARAT[ON ,•Aee�� APPLICATION FOR PLUMBING PERMIT
i hereby affirm that I have a certifica2e of consent to self ce n��x-eo� �
insure,or a ceRificate of Workers'Compensation Insurence,or
a certified copy thereof(Sec.3800,Lab.C� COUNTY OF LOS AN(3E LES BUI LDING AND SAFETY
Policy No. Company� .
1 � Certified copy is hereby furnished. FDR APPLICANT TO FIL4 IN IPRINT OR TVPE) BVILDING n �I�I,� �
�f NUMBER FIXTVqE OF ITEM • FEE AD�RESS 'd L!
�p� Certified copy is filed with t c nt b ilding lnspection LOCALITY �
Ae r en. WATER CLOSET
DatetiCf�Applicant NEAREST
BATH TUB CROS3 ST. �
CER7'IFICATE OF EXEMPTI FROM WORKERS' -
COMPENSATIONINSURANCE . SHOWER OWNER
MAII –
(This-section need not be completed if the work involved L.P.VATORV qDDR�55 � � 0.
by the pexmit is foi one hundred dotlus (5100)or IessJ SINK
CITY- TEL.NO.� U.y�(� U
I certify that in the yerformance of the work for which this DISHWASHER � �
permit is is ued.I shell not empl ny person in any manne[ CONTqACTOR p
so as>to b co e sub)ect to the o ers' �nsation Laws. . CLOTHES WASHER ADOkE3S`� � � J �� U
Date�� 0 ApP��cant� '— � a
SWIMMING POOL RECEPTOR
NOTICE TD ANYLICAN7:If,afte aking this Certificate of CITY "— TE�.NO. �"� �
Exemption, you should become subject to the Workers' LAWNSPRINK�ERSYSTEM STATE /� 1 y(� LIC� Z
Compensation provisions of the Labor Code,you must forth- LICENSE NO. �o�.�{� J d - CLASS
with comply with such provisions or this permit shall be WATER HEATER ^�'
deemed revoked. GAS SVSTEM OVT�ETS DISTRICT NO. . �(��P OCESSEP BY
LICENSEDCONTRACTORSDECLARATION OUTLETSOVER �� \�t�A'ySl,.
I here6y aff'vm that I am licensed under provisions of Chapter 5 PER SYSTEM �
9 (commencing with Section 7000)of Division 3 of the Busi- FiNAL J� . VALIpATION
ness and Professions Code,and my license is in full farce and DATE �p�(/��- ,
effect.
���Q�� F�NAL
LicenseNumbersX.11�li:_ Lic.Class ��� . BY �� �y..,,i �
Contractor`��=� Date )) N ..
� I am exem from the licensing requirements as I am e Plan check fee rJ (3 0 J �� ' `6'J���*�V �t haf_
� licensed archltect or a registered�professionai engineer (� O � �
� acting in my professional capacity (Section 7051,Bus- PLUM6ING PERMIT ISSUING FEE$ E
iness and P+afessions Code). � TO7A�FEE 2 " `� ����� .
.,t�RA'��
Lic.or Reg.No. �ate Plan check appiicant � � . p �
;��.(�,f,�7..r.
� HOME OWNER-$UILDER DECLARATION Name � _
i� . - .. . .,
I hereby aFf'um that I am exempt from the Contrector's Address � -
�. License Law for the following reasoII(Section 7031.5, Busi� City Tel.No. � � � � ! ` ., -
', ness and Professions Code): �
' � I,as ownet of the property,am exdusively contracting _ � a � � �'
with licensed�contractora to construct the project . ! ; ��
(Section 7044,Businees and Professions Code). ' � `� " ��� �
CONSTRUCTION LENDING AGENCY � �
I hereby aYfirm that there is a construction lending agency F,���� �
for the performance of the work for which tMs permit is . �Y h ��
issued(Sec.3097,Civ.CJ. �� ���f �
Lender's Name � ��'�SA�t.,1.jQ
Lender's Addresa �
7 certify that I have read[his application and state that the
�, above information is correct.1 agrae to compty with all County SEE REVERSE FOR EXPLANATORY LANGUAGE �
ordinances and State laws regulating Plumb�rtg, and hereby
� authorize resentatives of this County to enter upon the
above- nti ned ro erty for inspection p r�
� �
Signature ermittee Dete
# r .y� . ,� � a
-; - ----- —-�: - ,����� t �..� .uE.«.a<r.ri-.,•...�r, ii.�iao.
r — " '"-�— � INS,'CCTOR'S flOT�S �
PP�RpVF L DAT[ If-�.i_Crpf�55IGNATUI'G __��. _.._. � ON'NIsR-BUILDER DECL.ARAT�N
pJ�D-FSLFR�OS�: - —�
y, i
-- - —� � -- ---` I hcrcUy afd"a�n thaf I avco exempt Srom the ConEracEor's
FaoucF{F�u �t��r c i ��Lieense La+n� P��s the PolWwing xaeaen(5ecrion 7�3I.5.
_..1 ..__ ....�_ eae
�� �5 P�p'�� .. .. . . Busir+Ess and .�rof�s+'ioms Code/: Any ciry or cowHty
ir o
� �a �, rdr ._r �� — �- — .� . . whtch re�u;res ¢ permi; ro co�strurr. after. improve.
- - -- --
� �rv� ;-�t�-� �r �t � I . . �_----. � rkrnokek,ar re�arr anY'st.v.+cture,prier to its issuautr.
--t I � � al.ao requires t7ie app(ieant for such-permit to file a
��. LU�h�N.;F� 1J tc� � � � sigr:2d �.rtrrl�wr�eF that 1� is lir.ewaed pufs�wrt to the
p — -. _� _�_ __..,�_�
F E=T f � - � provisions of tlie Coretrertw's Liccvrse Law(Cleopter 9
f�riu�Co.r nr�o� _�._ � .� --- . . . . , /cowrrr�enei� with 3ectien 70Q@�J oj D/rision 3 of the
-��- - L Busin.��ss axd Pbfrssioe�s CodrJ or thw he is exemgr
therefrom.aa�'tlrc haces for the olleged exemptioce.Atty
� �h'�-.—- - f%.�s.:w5. c'+t �r r.'ae-� --,--:._� v . ' weFarien of Section 703/.3 bY anY W+plicant forc perxit
. . � � , --- s«h)ec[s Yhc rtpp7ieant to a crvi!/xnalty of not more thsn
� --- ---- • � jive huradreddotlers/SS00).:
--- ---
'���0U�TRIFI ' � � �
��a 7s_r,PF E uva� � �' � ------ ❑I.as owi3er of t#w�operty�.wiil do the woek,ancl
: . .,:.. . . .. ,� .....r..._ � the sFeusiun ie n�E i�rtei+Aa�i oF o€3ered ff�r s�ie.
. � . . . �..__. �S2C. 70�� ]�q6tBn3'¢i1�PY8jB0'SlE)NS CtNIF:.�Th€COYI-
' . ' , � ' ' _ !�^¢.;16I5 L[C��idd �QW U�CES re�t OPJIf'j� t0 OH OWHQf Of
��-�F�- � � - �, � � _ pronerty.k+.ho betiMs or irnproves therc+r�n,m[�who dsas
. � .. . . . . scerh H�ark hiriee�lf pro:�i�rd that surh iinpreve+ne�ets
• � _, arc not intexrk'�f or off�Ia+"suk. If, 1re+Veve+', the
� w � � . . . l:xilding ar irr.provemertr i.c so(� witl�a ope y�ear of
� . � � �� � �— . � cafr+¢ietiow, tfie owrts��-butlAar wrli hai+e tke I�arrlerr
� � - � � � of proring that he di�l r.oJ beriW or impeovo for the
, . _ Pw�"f�ae of sol�.�. .
I am ekempt un[}er�ec. ,
B 6r F.C.for t6is reason
-- --- Ilate
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� INSPECTOFi'�IlOTLS��--^�� -
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