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WORKERS'COMPENSATION DECLARATION APPLICATfON FOR PLUI�ABIN� P �
I here6y,affirm tho-1 I hove p ceriifimte o!consenf fo saff in- ��bjq PW 4�8�
sure,or a ce�rtifimte of Warkers'Compensation Insvrance,or a CE en(aEv.B'86)
cerrified copy thereof(Sec.3800,La6.C.)
COUNTY OF LOS ANGELES D6PT.Of PWBLIC WORKS
Pollcy No. Company
Q Certifled copy is hereby furnished. .i. �
FOR APPUCANT i0 FILL IN�PRINi OR TYPE; BUII�iNG �/ • �� ��
� Certified copy is411ed with the coonty 6uilding inspeciion ADouESs (P
deparfinenl. NUMBfR FIX7URE OR li'EM �' FEE �OCALITY
WATER CLOSET�TOIIETI � �1'� � �"
Dote Applicanf NEARE57
CERTIFlCATE OF EXEM9TION FROM 1h'ORKERS' BA7H rUB �+,� ��-j� Ce055 Si. _ c P
COMPENSATION INSURANCE ONMER �
SHOWE�2 �„� CrZ/
(Fh{s saGba n�ad�rof h�wmp4N�d if Th�work involr�d by h1Ait
Ma parmit is For ona Mmdred do{lon(i1Q0}or laaa.) LAVATOkY -�^ ,� �j nooRess �
I certify ihat 1n rhe performance of the work for which ihls per- 5!rlK � �''7) C�iv 7EL.NO.
mit is issued,I shall not employ any person in any m sc
as to become subject to the Workers"Compensatlo aws. pI5HWA5HER '�,1
T �V CONTRACiOR �'� ��
DWe`��=�-L.�+��-Appliconr - �'—`� CLOTHESN/ASHER �Jv ADDRESS � � � .
NOTICE TO APPLIGANT:If,after g thls CeNi c te of Ex- SWiMMwG POO�RECEP70R � �
emption,you should become su6jed�o t6e Wo rs'Compen- CiTv�'�,������t `,� L O. ���f���-
saflon provisions of ihe Labor Cade,you must fonhwlth comp- �,qWN SPRINKtER SY576'v1 �'
ly wlth such provisions or this permit shall be daemed revok- SiArE uC � f
I LICENC�NO. �� L` CLA55 4
ed. WATER HEAiER (J��
LICENSED CONiRACTORS DECLARAiION GlSieiCT NO ceoCe55E�e�
GAS SYSTEM pUTLETS ���
I here6y offirm that I am licensed under provisions of Chapter L• �L� Qi�..
9(commencing with Section 7000)of Divislon 3 of the Business OU7LET5 OVER
5 PER SYSTEM
and Professions Code,and my license is in full force and ef- FINAL �/A�� /�'f�0(f >'
fect. ,,��....� � ���-� !�(� pATE t-���. .� �,
License Number +?' �� lic Class_..L�— FINAL �
Contrac�or ��''����"K Do7e BY 6 -
� I om exemp�under Sec. "�" � � � _
B.BP.C.fo�ih�s reason Plan check fee �,
�
�aie: PLUMBING PERMIT ISSUING FEE$ lv �J
Slgnature ��C3( Z]
TOTAL FEE ��(�}`�
SINGLE FAMILY �plon<heck opplicom �-'���}'t!
HOME OWNER-BUILDER DECLARATION �
i hereby affirm that i om exempl from fhe Contracior's License Namg � ^� �'L,���'
Law for the following reason(Seciion 7031.5, Business and _
Professions Code): Address ° '�. � �-, ,. � �.
� I,os owner of the property, will do the wark and ihe Ciry Tel,No. �;4� � C—�;�;
shuctura is n�ot intended or offered for sale(Section 7044,
�sir�ved R+ofassyeros Code). �
� CONSTRUCTIDN LENDWG AGENC�
I here6y o4firm that thore is a consrrucrion lending ogency for
fba pes3crn,mAee of 1he work tw which this permir Is iss�ed
l�s 3i�,4i..6.)•
tendwr's Moma
Lender's Add�ess
1 certlfy that I hove rsad ihis app�ication and siate thot the � .
obove in4ormation is correct.I ogree�o comply wiih all County
ordinances and S�a�e laws r �g Plumhing,and here6y
outhoriza represeMatives �this Counry to enter upon the
obave-men' proper forinspectio�purposes.
�}:tCr.� SEF REVERSE FOR EXPLANATORY IANGUAGE
/
�I�nwne�r� Dare �
t�
� -� � 1 �•�` .
�__�.++a.��.--��E.... ,. �+�rwor��
RP,=ROYAl9 OATE INBPflCTOR'SSifvtMTURE ��_.._..,�..,.Y._...��'.'Y,�..'t?.^e'�,N07E� Q��B��F`����a��n�N
�UNDER�UIB WORH N � hare6y aftkm tAh I em w�amp!hom tM CaMraclw"s
.. -- ------ Llcanae Wv for tns f01MNrinp roabn (SBct10/7 7031.50
roa
��FOl1CH PLU6duING guglnev and prol�8lW�s CodeJ. Asy clty or cetmt�
ca,,P�a�� which�eauitea a Ae�mlt ro oonefrt�l, aker. lmprora.
�cE;s vEr.' � � � danroNsh or repelr 3ny sPructure,
arior ro rre issuance,
�r�or wnTr i H Ee�rEa — etso rgqtdre.4 the eppf�Canf htr sueh perrttR to fNp a slAr+ed
y.PiU�6GIM6 FI%7URL� � : �V_'— 9rBI@AIB('i�fH$L/IB%!hC&7$9fJ�AI1fSY!$Rf�J(H@/NOVfS7fMd
.� ottheconriattorbucenseEaw(eh�ore�s(comme»cMg
4�GFS TEST . Wlfh '58��/fXt�f Of 0lYISIOII 3 O/1(16�ifSM�$9 2tllf P/O•
�,urwsr co.r�ori�iEo ,.��___.__�, iessiafs GoCe)or thei he ia earempt tlt9relrom arNY the
bests tor the aHeyed exem,pt�.Any vkNetiw�o/S�tfon
4i F��,n� �'„t,�,.on.�.�e ---- ��on��jr n�o�i nor�rn�reve�nuau�red
�" _______ - - obders(s5flo):
`�i n ousrFlrz� .❑1,an ownar oh tlle propWly rrill tlo ths xro+k.mtl ths
Fwasreq�=v�ova� � . - � ------.-.---- steu�ureltmllnbndetloroff�naqfflreak.
,- Y+ (SBC.7944.&t9et�ss8I1dPN�e89�09C�4:T1IeContftC-
- tor's Ucense tex�rrot apply tb 9n owlrer otproperty
w/h�buiRls orlrt�A�ves theteorr,amf who do�suoh woNr
� �...._.� AlmSe(f provid6�Y fh8t St�ch Impl0v6rfrBnt9 ArB rrot intBntl-
ed or oHereO ior sata IF,hpwerBs,the 6uifdhl�a Im
--_____�_,. ,wovemenr!a sob wtthin orre year ol completion, the
owner-Wrila�r wXJ have the 6u�den oF proring that ho dia
__.�_� _. � met duild a lmprove ior tha,0urpo�af.sa1s)
�._____._---- !8111 9IIBfl1�?t ulld6l'$B�.
�~�.--- B&B.Co fo►ttdR►et�pr►,. -
� ______._.__.______..----___—� Dete- - ---
__.---._._.�__.�_ Owner
�..�_o.�._.���679R'8 NOl'�$ __—_---
�___.— _� �. ��
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