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Home My WebLink About1220A . APPLICATION FO P UM ING��MIT G��`� � F DECLARATiON ^ I hereby,affirm tho�I have a certifica�e of consenl lo self 76A687A �� i�sure,or a certificote of Workers'Compensafion Insorance, CE 817(REV.8/B6) V or a cerrifled cop there !(5 a L 6.C.� O�Y��Q��P nY '?11'� �j�� COUNTY OF LOS ANGELES DEPT. OF P�BLIC W(1RKS �_�.� �JY Cerfified mpy is hereby fumished. aFOR APPtICANT 10 FllL IN�PRINT OR TYPE) BUILDttJG �p Cenified topy is filed with ihe county build�ng inspao AODRE55 0 �C.. �) fion depanment � NUMBER FIMURE OR ITEM � fEE ��A��t� �f Date �� Appli4ant��NPII �b WATERClOSET '`r NEARE57 ��G�)N� ��'J . CERTIFIGATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. �I//� , � �" COMPENSAT�ON WSURANCE SHOwER .. OWNER �,(�� (This section n�ad�wf bs compbad ti ih�work involv�d by MAiG tM parmit ii;or onr bund�.d dollon(;loo)or I�ss.) uvqrpar ,yopRE I<ertify rhat in the performonce of the work for which rhis � �/ permit Is issued,I sholl nof employ any penon in any manne� / SINK CITY Q 4'�1� TEL NO..f? so as to become subject to rhe Workars'Compensafion Lows. Di5HWA5HER ./ /j��/�Q �p CONTRACTOR�G�'''CJN�r�- .Uf ,�/7I�� . � App�icant CLOiHE$WASHER AODRE55 'V � � .iCE TO APPLICANT: If, afier moking this Certificate of -�� empfion, you shauld become subjecf ro fhe Workers" SWiMMWG700LRECEPiOR Compensotion provisions of Ihe Labor Code,yoo must forth- CIT �r T .N � � wilh comply w�1h such provisions or fhis permit shall be �WNSFRINKLERSVST�M . STATE �IC. !� deemed�evoked. WATER HEAiER LICENSE NO. � CL455 [/ b LICENSED CONTRACTORS DECLARATION �ISTRIC7 NO. PROCESSEO BV I herehy affirm tho�I am licensed under provisions of Chopter 9 GAS SYSTEM OUTLETS (commencing wi�h$ection 70p0)of Division 3 ot the Business OUiIETSOY[R �� .'� ond Profassions Code,ond my license is in full facAa and eff�fetl. 5 YeR S�STFM FINAL VAIIDATION C7 License Number��"�Lic.Class�^�V DATE � :??-/S'6' f,7 /�� ] FINAL � � Con+rocio are________1 / BY �� U � W I om exempt vnder Sec. � B.&P.C.for this reoson � Plan check fee \ � ►- ��e� PLUMBING PERMIi ISSUING FEE S slgnoru�e a r 1 2 2 0 R TOTAL FEF t�a > • • •5 Ptan chack opplicont SING(E FAMIIY I � ��'E.S n . ^ HOME OWNER-9UIl0ER DECIARATION Name ,_ �,;� ..•ereby affirm tha�I am exemp�fiom�he Contractor's Licensa .Ad�,�B ' ` �� - , Lew for.rhs following reoson(Secfion 7031.5,Business and @ J Professions Code�: Ciy Tei.Na. Q�"� �g� ❑ I,as owner of tfie properiy,.will do�he work and ihe � struuure is not intended or offered far sale(Section 70A4,Business ond Professiwis Code�. � CONSTRUCTION 1EN01NG AGENCY I hereby offirm fhot there is o construcfion lending ogenoy for tha performance of�he wo�k for which this permif is is�ued (Sec.3097,Civ.C.}. Fl11�li�9�IQ/l16� _- . . Lendo:s AddRaas - I certtfy rRm I hove read this applim�ion and s�ote�ha�ihe � abo�e infwmation is cwroct.I ogroe to comply wi�h oll Co�ny � o �nences and State lows reguloring m6ing,and here6y a tharize representaiives of Ihis Co to enter upon the ove-menti ed prop 1yy to ins i purposes. 7 �`� SEE REYERSE FOR EXVLANATORY LANGUAGE � ��l Signalu e Parmiu . Dafe � i _ _ , . ._ ;� :�... _ -�...ra. • , , # .. . .� _� � . • , �* � , , , . -'- _ __ __.� ___ - -- -- _.� _.- _..____ �:��''" ' . ..¢ ----. _ _ in _ _ �__�_ �i� r i i � r [FF J f 5 pAT ((( S lJ' �T(�['. N"1TC, LAG 7F4: � I 1� I I . I . �5 � __—_ _ . _—' . ___._— __ . 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