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� WORKERS'COMPENSATIONDECLARATION App�,ICATIO�V FOR PLUMBlNG PERMIT
I hereby,aHirm rhot 1 have o cen+Ficaie of mnsent�o self in- ,��,A�4�8� �
5ure,or a cerlificate of Workers'Compensa�ion Insuronce,,or o CE B77(REv,8i86) ' �
certified copy theroof(Sec.3800,lab.C.� �
Policy No.1f1-f14R9A(16'ompony CNA Ina. Co. , -� � COUN7Y OF LOS ANGELES DEPT.OF PUBIIC WORKS.
� D;-Ce:fifled copy is hereby furnished. BuitDiNG
FOR APPtiCANT TO FIIL IN IPRINT OR TYFE)
, � Certifiedcopyisfiledw�ihthecounfybuildinginspecuon aooae55 1915 Brazos Plaee
deporlmenL�///�y� NUMBER fIxTUREORiiEM p FEE ip�AiiTY Diamond Sar
Dore� A�ppLcan� (Swr+n Rrns_ P7ho, wATER CIOSET(TOiLET� n�En�zE57 .
CER7IFICATE OF EXEMPTION FROM WORKERS' ` BAtH TUe � ,� CRO55 57.
CDMPENSATION INSURANCE / SHOWER � � ,r OWNER � M1SSlOtt Builders
(This s�cHon n�ed net 6�eomplet�d if fh�wo�k involv�d by MA��
M�p►rmit is for eno hundr�d dellars(f700)or I�as.) LAVAiORY - AD�RE55 8464 E. Garve Ave.
- 1 cerlify ihai in�he performance of�he work for which ihis per- / SiNK '� '
mit is issued,I sholl not emp�oy ony person in any monner so CITV Rosemead ,e�.n,o.286-8339
os to become subject�o ihe Workers'Compensalion laws. DISFIWASNER "'
CONTRACiOR pwen Bros. Plumbing, Inc.
Dote Applicant' / CLOTME$WASNER AD�RE55 4265 N. Baldwin Ave.
NOi10E TO APPIICANT:If,after moking�his Certifimte of Ex- . SwiMMtNG POOI RECEPTOR �
emprion,you should become subject to the Workers'Compen- CiTv tE�.NO.
� sofion provisions of Ihe LobarCode,you must farlhwith comp• �AWN SPRINKIER SYSTEM EL Monte 443-0078
ly wirh such provisions or this permit sholl be deemed revok- SiA7E 231 7[+1 uc� C36-20
ed. WATER HEATER .1 LiCENSE��0. CtASS
� � LICENSED CONTRACTORS DECLARATION . �iSTRiCT NO.O t/� ,QzOCE�D BY
I bereby offirm ihal I am licensed under provis�ons of Chopter GAS SYSTEM OUiLETS 1 '`v\(1\t
9(commencing wilh Sec�ion 7000)of Division 3 of the Business OU7lET5 OVER � `��`�Z����
��d Professions Code,ond my license is in full(orce and ei- 5 PER S�STEw7 FINAL VALIDATIDN y �
DATE � p
�icense Number 237. 741 Lic.Class r.�F-�n �
FIN y-
Contracror��an Rrnc vth..pa�e R_ln_AR BY O
r
� I am exemp�under Sec. � . W
. y
s.Br.C.for�h�s reoson Plon check fee , �
Date: PLUMBING PERMIi ISSUING FEE$
SignoWre
TOiAI FEE �
- SINGIE FAMIIY
HOME OWNER-BVIIDER DECLARATION Plan check opplicant
I hereby offirm that I om exempl from the Comractor's Licensa Noma . �
� Law(or the following reoson(Seclion 7031.5,Business ond � ' � - ,
Professians Code): Address �
� I,as owner of the property, will do�he work and the Ciiy . 7e1.No.
slrucNre is no�intended or offered for sola�Section 7044, �0 9 1,6 A
Businesz and Prolessions Gode). ; � � ► # . • . . .J �,
� CONSTRUCTION LENDING AGENCY ' � �
I hereby affirm that there is a constroction lending agency ior . - � � •7 a Q Q
ihe performanta of ihe work for which�lhis permit is issued ' � �
(Sec.3097.Civ.C.}. � • • e'��„(?'(j�
Lender's Nama ��� 7_8�
Lender's Address � � /
I tertify thof I have reod�his opplica�ion and state thot�he - , � / �
above informa�ion is correU.I aqree ro mmply wilh oll Counly
ordinonces ond Stafe lows regulating Plumbing,ond hereby � . � /
th ize re e ntotives of his Counry ro enter upon the � ���� '
e-i e�prope F i spection purposes. - j �
SEE REVERSE FOR EXPLANATORY LANGUAGE
� gnolure of Permiftee Dole � �
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