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� WORKtiRS'COMPENSAT[ON DECLARATIOV >saeetw J7
.ereby affirm �ha� � heve a'certificate ofconsept �o Se�� �g.�>,z_ao, APPLICATtON FOR PLUM�.SlN-.G PERMIT �,� �
��. ure,or a certificate o}Workers'Compensation Insurance,or I'
ertified copy thereof(Sec.3800,Leb.C.) COUNTY OF LOS ANGELES , BUI LDING AND SAFETY "
�licy No. Company i
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OF TYPE)
BUILOING � �
�Certified co y is flled wi[h t unty b ild'n ADDRESS 7
p g inspection NUMBER FIXTURE OF ITEM • FEE
de�/ap/f m/p�'�jt. � WATER CLOSET �OCALITY
bate'�7_nP�_Applican[ � NEAREST .
+ BA7H TUB CROSS ST.
. CERTIFICATE OF EXEMYTION FROM WORKERS'
COMPENSAT[ONINSURANCE SHOWER OWNER �
I.AVA70RY MAIL
'(Thia section need no[ be completed iq the wock involveci ADORess
; by the pezmit is for one hundied dollazs ($100) or less.) S W K y
CITV TEL.NO �
� I certify that in the performance ot the work for which this DISHWASHER U
� permit is issued,I shall not employ any person In any rnannei CONTRACTOR
� so as to be me subject to the ers' . mp isation Laws. CLOTHE3 WASHER �+f �
Dete�y�°,�Applicant ,.� ADDRES�Gi Qe�'B � � O
SWIMMING POOL RECEPTOR , V
E�mpion�you sh udT�becomersubkect ro'$het�Workesr LAWNSPRINKLERSYSTEM I 5 ATE � d IC. NO.e',�j, - �
Compensation provisions of the Labor Code,you mus[forth- WATER HEATEF � LICENSE NO J r CLASS C.-�'✓ Z
with comply with such provisiona or thia permit shall be —
deemed revoked. GAS SVSTEM OUTLE7S DISTRICT NO. PRO ESSED 8V
LICENSED CONTRACTORS DECLARATION OUTLETS OVER O �C�GL-L�
1 hereby affirm that t am licensed under provisions of Chapter 5 PE R SYSTEM
9 (commencing with Section 7000)af Division 3 of the Susi. FINAL
ness and Professions Code,and-my license Is in fult force and oA7E � ��f�7). VALIDATION
effecA
FINAL�� ����J
,icense Num Lic.Class�. gV
Contrecto Date�� ` t,
� Plan check fee � C-�� '� �1� ' ���1'
I am ezempt from[he licenaing requirements as I am a �IL{,, �p p�
licensed architect or a registered profess[onal engineer pLUMBING PERMIT�SSUING PEE$ � /YI_
acting in my professional cayacitY(Section 705t, Bus- , Q .��
iness and Professions Code). TOTAL FEE �
Lic,or Reg.No. Dete plan check applicant �
HOME OWNER-BUILDER DECLARATION Neme � ����,n�
hereby aPfirm that I am exempt from the Con[ractor's �+ddress �a ��� �i'�TS �, �
/� �,s s�
icense Law for the followirtg reason(Section 7031.5, Busi- City ' Tel.No. � )�� y�i�.�
:ss and Professions Code): . v
� I,as owner of the property,am exclusively contracting � .
�vith licensed contractors to construct the project �1 2 9,4 A
(Seciion 7044,Business and Professions Code).
#� � �a �,fj
CONSTRUCTION LENDING.4GENCY
hereby afflrm that there is a construction lending agency� -� • •� 2.rJ0
rr the performance of ihe work for which this permit is
sued(9ec.3097.Civ.C.). � s a a�� `'j,rj Q�j
ender's Name
ander's wdaress �j',����
\
��Hfy that I have read this application nnd state thet the
`information is correct[agree to comply with atl County SEE REV ERSE FOR EXPLANATORY LANGUAGE
��Fes and State laws regulating Plumbing, and hereby
�:representatives of this County to enter upon the
�'�i9ned property for inspection purposes. �
C
� �
� '� rmittee Date '
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