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�� MPFNSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �
I hereby affirm that I have a ce�rificate of consent to self �yqy��q
insure,ar a certificote of Workers'Compensation Insuronc , CE BV(REV.70/87)
o�o cernfed copy rhe�eof Sac 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Golic No.�-�y�� 'F��� '�'/��
❑ Y 11.L✓–L.L� �pany �.a ^�' ��L.r+"
Certified copy is hereby fumished.
QF-0R APPLICANT TO FI��M(PRINT OR TYPE) BUIIDING ��O � ,•,}�
Certified copy is filed with fhe county building inspeo ADpRE55 /O
t� n departmenl. NUMBER FI%TURE OR ITEM Q FEE
,}���rr��--^'C�/r� tOCAIITY Ju M
�ate _Applicpni ��e� WATERClOSET ��' 0 NEAREST
CERTIFICATE OF EXEMPTION FROM WORNERS' `L. BnTH 7U6 CROSS ST. .
COMPENSATION INSURANCE OWNER � �
(Thfi section nwd nor b�compl�hd if�ha work Involvad by SHOWER
N�AIL
fbe permif ia for ono h�ndred dollars(5100)or la�.) �nvn7oRv q�DeE55
I cenify ihai in the performonce of the work for which this
permit is issued,1 shall not employ any parson in any manner SINK Ciiv � �.N . ��_ �/�
so as to became su6jecl to the Worker5"Compensation Laws. DISHWASHER
o �oNTa��TaR �,• ch�r f�/b
Da1e Applicant - CLOTHES WASHER O ADORE55 �C
r""`�TICE TO APPIICANT: If, afrer making this Certificote of �� / �n �C�
mption, you should 6ecome s�bjecf fo fhe Workers' SWIMMINGPOOLRECEPTOR
��ompensarion provisions of the Labor Code,you must fonh- GTY �.n fQ�� E .'�
ilh comply wifh Such provisions or fhis permif shall be �/+WN57RINKLERSYSTEM STATE LIC. /�
deemed revoked. WATER HEATER LICENSE NO. CLA55 C�.
UCENSED CONTRACTORS DECLARA710N DI�TRICT NO. PROCESSED eV
I hereby affirm thpl I am licensed under provisions of Chop7e�9 GAS SYSTEM O�TLETS �D O
(commencing wifh Seclian 7000)of Division 3 of�he Business OUTLETSOVER
'�, and Profezsians Code,and my license is in full force and effect. 5 GER SYSTEM fINAt �/ VALIDATION y
, 'SI J(J�J � L! DATE y .`��7s 6:
License Num6ar Lic.Class� �
c � FINAL ��yJ�l "L�}/ U
Contrador / •J'QY � Date�9–�� . By /J°"`.�"",s��//
�
� �
I om exempt under Sec. U
B.Bv.C.fo�th�s reason plan check fee "'�
Date: ;'� Fi 2.I A Cn
PLUMBING PERMIT ISSUING FEE$ Z
Signoture �i e a e a •,5 �"
TOTAL FEE
Plan check applicant
1 ^, �76,5Q
SWGLE FAMILY , a
r"
HOM€OWNER-BUIL�EH DECLARATION Nome " � �E`����'
� 7reby affirm tha�I am exempt from the CoMroctor's License Address ��,� 7–nv 7
w for�he following reason(Sec�ion 7091.5, B�ziness and
Professions CodeJ: " Ciry � Tel.No.
❑ I,as owner of fhe propeny,will do Ihe work pnd Ihe ,
slructure is not intended or offered fo�sale (Sedion
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY �
I hereby nffirm thot Ihere is a consh�ction lending agency for ..
ihe performance of ihe work for which this permit is issued
(Sec 3047,Civ.C.�. �
ICJIddF9�.
Lender's AYYdra�.
I certify that I have read this oppllcotion and sta�e fhot the , �
above informotion is correct.I agree to comply wirh a�l County
ordinances and Stqte laws reguloling Plumbing,and here6y
ou�horize representotives of this County ro enta✓upon Ihe
obovrmantioned prope.ty far inspection purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE
�� - ,, �11-�z
Signoture o Permittee Data
_ _ — _.�� i� � - _-� _ �- _
�� +*..r. �..� �r.
'. �.y ,�� '� �7�!4 1 �► �i/
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arF � at cqiE wS�e R' tIGNATURE INSPECTOR'SNOTES___�� O��itVER BUI,.D�k�E�4RAilON
Uti�ER ,Fl V —j � I hereby off rm thai I am Pxe �pt om iFa Cc���a•te�'a
R�UCH C.0 J I ., � �_ L�censa L� for the Fo�low�n ason (5=t on 7031.5.
\ � 9
GAS F��P,^J�^- _. __ I,��� � 8usiness and Frolessiona Code�).Any city o rounty wIi rh
G-5 V[P. requires o perm7t to consirun,aHer,improve,demol�sh.
� �or Yepoir any strucfure, prior ro ih issoo�ce, also m-
H7i N'ATE�:ti`4TEF -.��� '—
qulres fhe apPlicant lor such permit to file a slgnvd s�o�e-
�P�.UM9CdG FI�t7.::E� � � � enf thoi he'rs Ilcensed pursuant to�he prov;slons vf fbe
GASTE£T � I/ Confractor�s License Low(Chapter 9(commonciny�•�i;h
UT�LITV�O.NOI;°'��EC x� SecNon 7000)of Oivision 3 of ihe Business and Profes-
—�..._ � sions Code)or thaf Fz is exempt Yherefrom and Ihe basis
� . � �, � � � (or fhe ollaged exempfion. Any v�olalion o� Snc�ion
i`---.--.`___._ c'�
��'�- P ufrr on ,.i�ronf � - � � • ' � �03L5 by ony applicant for o permi}subjecfs}he appli-
tant to a civif penalty o(no�more�han live hunetred
�`T - dolfars($500).:
INDUSrFI::i . � � []I,as owner cf�he property wlll do�he work,and
WnSTE nrp;;C'✓�.L � � � �� � � � the shucture is not Intended or offered for sale. � �—
4 ' , , (Sec.7044,Busf�ss bnd Professions Coc'e: ihe Cc r
� . � - � � lor's Llcense Law does not apply lo an owner of property
. who 6uilds or Improves /fiereon, and who daes such
� � � , , work Rimse(f provided thaf such improvaments cre not
. fntended or of(ered tor sale.If,however,iFe building or
� , , . � . �— � , improvement Is sold wifhin one yoar of completion,Ihe
� � owner-buifde�wil)have}he burden of proving fhot he did
��� � not butld or lmprove for the purpose of sale.)
�I am exempt under 3ac. ,
8 8 P.C. for this reason
i_ Date
Owner
� �� :?�CTOF'S NQTES