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�WORKERS'COMPENSATION DECIARATION qppLICATIQN F�R PLUMBING PERMIT -�(
I hereby affirm ihar I have a certificate of consen�to self �bqy��q
�insure,or a cerlificale of Workers'Compensafion Insuronce, CE 817(REV.10/B1) U
a�a certified copy thereof Sec.3800,Lab.C.) ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
��YN�2�73c�?�y_. Q -e �� 7't'a�� yzs � 7��'2Z-
Certified copy is here6y furnisbed. �
� FOR AVPtICANT TO FILL IN(PRINT OR TYPE) BUILDING /?/_O � � �/
Certified copy is filed with the couNy building inspec- ADDRESS (:��
tioade arfinenf. NUMBER FI%TUREORI7EM Ca FEE , �r
LOCAIITY �
�'^� �.�!' ' '�` WATER ClOSET d
Date � � Appli4onl�_��• � CRDSSST. /C{/� �'
CERTIFICATE OF EXEMPTIQN FROM WORKERS' BATH TUB
COMPENSATION INSURANCE SHOWER OWNER �
(TAis s�ction n�ed mt lw complefed if fhe work Inwlved by Malt
Ihe permH is for ona hundr�d dollun(5100)or Isas.) �„ tqvATORY L} ADORE55
1 certify that in the performance of the wo�k for which this /
permif is issued,1 sholl nof employ any person in ony manner SINK CITY � ` � .NO. � �
so as ta become su6jec�to the Workers'Compensation Lows. � DISHWASHER
COMRACTOR f �`/ �
S'-`� Date Appli[ont � GIOTHES WASHER ADORE55 tG �
;�-"'�TICE TO APPLICANT: If, after making Ihis Cerlifimte of SWIMMINGPOOLRFCEPTpR
� :mption, yau should become subject to the Workers' /¢sJ `
. l.ompensation provisions of�he Labor Code,you musf forth- tAWNSPRINKLERSYSTEM Clry �G �'Q' Lf� ��
. wi�h comply with such provision: or ihis permi� shall 6e SinTe uC.
� deemed revoked. WATER HFATER ,r� UCENSE NO. CL.455
L�CENSED CONTRACTORS�ECLARATION v DISTRICT NO. PROCESSED BY
I hereby affirm ihat I am licensed under provisions of Chopfer 9 GAS SVSTEM OUTLETS
(commencing with Section 7000)of Division 3 of 1he Business OUTlEi50VER
' and Rofeuions Code,ond my license fs in full force and effect. 5 PER SVSTEM FINAL �/f,��� � VALIDATION 1.;
Ii�� ��.,p/� �vF��� DATE `�
License Number_(L' �..Z.Q LLic.Closs� �"
O
' `j Il R 1 FINAL.�1I��� �� �.
Contracror afe_ gY �uu a.
� O
( I am azempt under Sec. U
B.dP.C.for this reason pian check fee a�
oo�e: �1 8� 1 A N
PLUMBING PERMIT ISSUING fEE$ �, �5 Z
Signoture t,. o e • a _
TOTAL FEE
In =7650
Plan check applicant �
SINGLE FAMIIY ,. ,'��!. r.,,r�y x
HOME OWNER-9UILDER DECIARATION Name
�qreby affirm tha�I am exempt from Ihe Contrac�or's License Address ��'� ���7
..aw for�he following reason(Section 7031.5, Business and
Professions Code): Ci�y Tel.No.
❑ I,as owner of 1he property,will do fhe work and fhe
sfrodure is not intended or offered for sale ($etlion �
7044,Business and Professians Code).
CON57RUCTION LENDING AGENCY
I hereby affirm that ihere is a construction lending agency for
the perfnrmonca af the work for which Ihis permit is issued
(Ser.30�i7,Civ.C.).
L-ertder's Ftmrte �
LemJer s Rddress
I cerri4y fhof I hove read fhis opplication ond slate Iho1 the ►
above informa�ian is mrrecf.i agree to mmply wilh oll Counly � �
ordlnances and State lows reguloting Plumbing,and hereby
ou�horize repre'seNolives of ihis Couniy to aMer opon ehe .
o6ove-menfioned property for inspection purposes.
/� ,, SEE REVERSE FOR EXPIANATORY LANGUAGE
�.�s�c���s�i�e�,
SignaNre of Germittee ��^ Dot��T-
: � _ — _ _ _ ��� �' -�wr� n.Ii aF •�,� �.� � .
• �. . � �..« ._..� . . . � � .. . �... .
Avrp:'�`.'At5 �� AT iNSP OR' SIGNATURE INSPECTOR'S NOTES - - O4+iIVER-BUIlD6R DEQ.ARATION
.
x UNCER '1> H 'I � . � , � ! here6y affirm�hat I om Prempl f om th�Ce,t c ��o�':
ROL H P t�.^ !, � I - � License Lavr for Ihe fo�low�ng r ason (SeH 031.5,
— ... � . —`....—'. '_ 6usiness and Prolesswns Code)�Art cif or coi nt �h
GASFiP�h,. i ..1. .. Y Y Y.,�`•,�
GnS4'ENi ^ requ'rres o permlt fo cansfruct.al�er,improve,demolish.
, . - or lepoir any sfrvctwe, prior to�ifs issuante, also re-
HOT N;ATEr!;�,�;:,- I ' � �� quires fhe cpplitant for soch permil to file a signed s�are-
PLUMBIn:G=bv11.qE; '� � � � � ment fFat he is licensedpursuont to tl:e provlsrou of ths
GAS TES7 j j1�r� ' � Contracfor's LJcansa Law(Ghapfer 9(commencing aaih
�U-1lITV CO.�ti'O?I=fE7 � ' ' Settion 7000)of Olvlsion 3 of fhe Buslness and Profes-
�� --.------� � s�ons Cods)or Nwf Fe is exeropr tiwrafrom cnd tho basis
'�.____.___. ��_� �. '�I � �or the olleged exemption. Any v�olallon oi SeUion
FiNAL ,., � � ' �'.<��, � l � � 1 . . 703i.5 6y any applicant for a permit su6jeds fh^oppli-
r nrt _ ro�a �� � cant to a civil penolty o(nof more than five Fundred
—.z__--------- �
� � � - � � . , � dolfars(S500J.: -
WCUSTf°::4L �- , . • • � ❑I,as owner oS the property�vill do the work,end
�•ti.asie nFr'�.�'v,�i. ��- � � ----��—�- � the skuc�ure is not iNanded or nfiered for sale. �— �
����, � ' . (Sec.7044,Busfness andPro(essions Code: The Co
�� - _ ` � � - tor's Lleense Low does nof apply to an owner of property
, . . who builds or(mproves thereon, ond wFw doas such
' � � � _ � � work hlmsalf proNded tlwt such improvarcwnis are nof
intended or offered for sale.f3,however,the bullding or
� . � ' � .� � . � improvement!s sold wJthin one year o!comple�ron, �he
, - ' owner-buifdcr wlfl have fhe b�rden of proving rhot he d id
nof bW7d or improve for the parpose of sale.)
i am exemp!under 5ec. ,
� B&P.C. for ihis reason ��
�
` Date
Owner
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Shd5FcC1'OR'S NOTES
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