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1353A (7)
,� _ ,�., ,� _. . . _ . 1 WORKERS'.COMPENSAT�ON�ECLARATION �� � : �� /�ppI.ICATION �QR�PLUMBING�PE � . � I-Aereby affirm thaf I have a c3rfifimte�of consem.to self -76A667n � .. � . . .. . .. . � . . . � - , ' � � �� ? . �� .insure,or o certificate of Workers'Compensafion Insurance, ..CE 817{REV.10/&t) . . . .. ., �. .�. � �� .. �� ..� . � or o ce�tified copy+hereof(Sec:3800,�ab.C.) CCUNTY OF 1,05 ANGEiES BUILDING AN6 SAFETY 1 � Poficy No � Company _. . . ....... � ._ >. .. . . . : . . . ... . �.,. . . , . �. � .. � LJ �enified copy Is heroby furnished , . � . . .FOR APPUCqNT 10 FILUN(PRtNT OR TYPE) OUILDING. ,� .'.., ' `�:CI__� ��' Cerllfred copy-is flled writh Ihe couMy�buildi�g-inspao � AODRES$ � � �C(9C� �� 1 � ..., , . ' 'NUMBER. . . ffMt1REORlTEA1 . ���. . .FEE ... LOCAqTY . . . . ; ... � � �tion deparlmenL . � � . ` �afe �. . ... APPIi4onf� " . . . . ' .._ WATERCLO$ET �. . .. }�� �'/+ .. . . ____-- . ��-�'... . �. NEAREST ,� L II � rI/N�Y � '`� ` � CERTIFICA7E OF EXEMP7I�N fQ4M WORKBRS � � � B/+iH 7UB - , CRO55 5T. . �� . . ._.. . . �. _ �.� . �� : � Y �. Iha permft is,for o ePhu drad doltan(fI00E or loss.) Y � tqVAFORV .qp�pReSS� � . This seetlon naad Mot 6e<om lefed H►he work Invelwd 6 ' Srrotv�R � � hcartity that in Me perfarmante�of�he�work far wfiich iMs � - � � � � - 1 � � ��� ..�permit ia�issued,4 shall not employ any person in any ma er � SinfK ���- - � - � � " -�-CttY�- � �." TEi Np. u� '� 5 ,,-so as W.become 6objetllo the Workeri ansption ws. -p�SHWHSHER ., . � � � ��� ' ' � . ` mnrtRnctoe /�t,�"'i i ;' ���Dafe��LApplimei`�� � CIOiHESWASHER - A�DRESS � � � . � � i NOTICE TO APPLICANT If, ofte�making ihis Cbr imte of � � � {:� � SWIMMiNG POOC RECEPfOR � . .. . -�Exemp�ibn,-yo� ahould become subleet to thc�Workers' Gtt �� �t.rv0. � � j. ��.�CompensationprovisionsaftheleborLode,you�:muatfonh- -. �qWA�SPRINKLERSYSTEM ��� �� � ' ` i .�.with.comply with such provinions or��his permit shall he - � � 5?n1E l�C. . .' � deemed r6vokEd. ��� �. �� :. , . , -� WAiER HEATER� � � � �1 IKENSE NO. � � CLA55 , 1 � � ._IICENSED(IONiRAC70R5 pECLARATION. .� � � �, , �' v.V� � DISTRIC7 NO. � � , PROCESSEo BY � I; . I hereby aH.irm fhot 1 om lisensed ynder proviiions pf Chapter 9 �. � .. � GAS SYSTEM�_�. :..OUTIETS�_ . ! . ...� . a .. . �' (commenatng with Sactfan 7Wp).of Diviaion 3 of ihe Bosiness . . .4UT�ETSOVER , . � � 9 ��and Professions�Code,ond my license is in full forca and effecL 5 PER SVSTEM�� � � FINAL ��r� > � V LIDATION . ��.� � . � - . . .4 DATE , i Liceose Number � � lfc C�asx � � o i ^ . . ., � •. ' G �,•�} FINA/L /�I � I. . C�. { .. Cootractor . . . . ��� � Date��� � � � � � . ., . .. �Y/�..�L �� � " .. - . — . . _. . ` � �, . ❑ 1.am exempt�under Sao � ... ... . , . � . . ., .�.:. . ... . �, ., . , � . .� y , 8,&P.C:for this reason P�aR Ch6Ck f@@ � - � � ' � � � � � � C : .. .._.. . . ,.....� .. . ._.. . . i .. . � DaFe: ' � . ' ' . ; � � .. RA � . � -0LUMBING PERMR ISSUiNG fEE S � p S� - . . . .- � j „�„� ��.� . ��.Signatvrc .. . .. . . ; .. . . � , . . ��TOTAIFEE , w , z13�3A t; . . .� .: . �I.� _.-. ... .. �, ' � � . Pfon the2kbPPrlmM .� � . . ' . .. . . .. , � . . SINGIE fAMIIY . . . . . - ���a ��� �fj .. �;�� HQMEOWNER-B�ILDER DECIARATION � - Name�. .... . ._ '� . � �� - � j , � (, �. I hera6y pffirm that�am exempt from the CoNroctor's litenx��� . Address - � � � .-. � � �� � � � ���s ��a�� `� Law for the followinq reason{Sec�ioe.7031.5,9usinees and _... . .. ... .�..� .� .. . . . �.., �. . . �.� Pro ssions Code): � . . � . . � City �Tel No. ��' ' � . . •�� �2 a 5 a c�i, � � ��I,cs owner of.ihe proparty,will do tha�work and the � ��� ' ' ' - `� �� ' ' � � � k - ttructare-ia not iMended ar offered fof sale�RSection � ��� S � O Q�L�T"'g 6 �� 7044,Busiqess and Professions Cade)., � � -- � � �- - �-'' , �� � � , -i � � � � �C6NSTRUCTION IENDING AGENCY � � �� - � ' � � � : . . ..._ . ._:,. .... . . �.:. . .. .._._ ,�_.. ,. . � 1 here6y affirm�hat there is a nonatrvctien lending ogency for � � - � � . � � . � . "� ihe per(ormance of ihe wark for which ihis permit is luued � " � . I�� � � � � . i �. (Sear3DAZ.Ci�.C.?. �. . � . . , -_._ . .. .�.:. .. ,.. _....: - .. .. .. :.. .; _ .. .. . . . � ; .. I. ,- � .. . . �.. - ! . .lender's Name . . . ,.�_: ; ._� . . . ..�_. _ .. . .__. . . .� . , . ... ��� Lender's Address. . . .. . � .... . _,_�... � .. , . . :. ..: . . . �..,.. �_ . . _ . � . . .. j . .. ,� J�certify ihot f have read this appficotion and state thm�the � � �� � � � � � ' . �nbove infarmaflon is corract.I agreelo aomply wi�h olI Couny �-��� ' - ��� � �- '��` ����-�-� ���� -�-� � � - ��� �� � � � -ordinances and Srpte laws iegu ting Plumbing,and hereby � . � �. . , � � � , � . � � � .� - . � . �- authorixe repr' tatives of 1 s Couoty�io enter upon 1he �... .�... . . . .--. . .. . ... ...:... ..... . , .._.. j.... ... . . � obove-me tio roper�y for�nspection purposes. . .. � � � ' � . � , . _ - I � �� ��'"]..�//� SEE REVERSE FOR EICPIANATORY LANGUAGE , f —� ..W _.. � , . . ' � c.....,�,�.a erminee � . .Da�e � . . _ ._. . .... . .. _.. .. .. . . � � . , . � _. __ r - -- --.._. _.__ _ __ _ _ _ . . _.,�_ . _ ___--- j ��F � �►�` , ����� —y4.. -��s. _+y �l+��•rr+rr�r- �� � �iNSPECTOR'S NOTES � OWNER-BU 1 -- -.- ���'��'^�•� . �..• .�. ILDER DEC1..4RATION- . . � AP%20VA15 ' DAiE INSPECTOR'S SIGNA7URE . � UNDERSIRBWORK � � � ��� �'���7 liereby-affirmifiaf�i am ezampl fram tha Contrcctor'; . ......... .. ... . . . .. . ROUGHPLUMBING ._,...� ,`,�j ". �^� f�. ' { .... � .. � ...... ... license Law for the�followinq�reason-�(Section y031.5. � GASPIAING. .-.•. . •- �'�". '.' � i.�..�:;.. .. ". -........'. ..'.. . ....'.. .:�.�`�. ....-... .._'.. . B�SlnfssandProlesslonsCode):Anydlyorcouniy..wh!ch ' "�' requfres a perml�fo construcl,ol�et.�lmprove,�demtil�ish. � GASVENT 3'i�t f Lar ..i�..A"i's.,. . � ,. ,. -..._. _. ._ .. ._ .. . . .. .� . � or repai�any struc}ure,pNar to Ifs 7ssuante, also re- ���.' HOi WAj R yEATER�, � �� �. "'� ,. :- ,r- . , . , . � .... . ... .. ... .�._ �. _.. > .-. quirn tfie oppbcaM for such permll lo file v r7gned sldio- ' vlUrne��G Pi uRES' ''' ��S �w`"'-��a'� " '-� ��� ��' '� � �"- -� � ment lha�he!s ileensed pursuant to the p�av�r�ons of the � � '�� GAS TE57 "7, �;;.ni,q;y t,� ' yE R,t��,,�� ' � � � � - ... . �. . [onfracfori Ylcanse taw,(Chapfer 9(commenNng a,itb � UTIqTY CO.NOTiFIEo , ,. r;,/ ��"-'���� ----- ���- -��- -�-- ��;��" -��.SeNian 7000}o!Divlsion J qi tbe 8us7ness and Profas- �., ._ .;� - ,� � � � � ilons CadaJ or ihot he!!szemphfharofrom�and�he basis � ;. ...... . ...".....c.7 ... .-. . ... .. . .. . .-. . ..�' . . . . ...-:�. - '......- . .: lo� ihe�a7leged exerpPflan.�Any.vloloNon o1.Sedion i. FlNAL� �.r �> �-`�i��'nfer ..J l . _ ._ ; �. . __ . .. . .. ... . .^ 7031.5 by any eppHtant foro-parmftsub�ects the uppU- on rort . � ����crrnt�o a.aWl penv7ty of,not more�fhan five hund�ed ' .:.�,��t := _ deuon�s�an�t�.., � ;� c'', ' WDUSiRIAI ' .. .. � ; �� � ...��".�•'�,I�,pR3a.y+ry�J({2f fhe proppFly�%�y do'�,work,'bnd �, WASTE APPROVAI . . �- � , , �, � .tl�q atrutlore is not inlandad or offered for sale. �".' ' � �.... . ,'... ':� �' . .._. �� . � . :. : �. ....(See.7044.lusiness orrd Professlons Code: �.7he Conlrac- . ', ' . ... ....._ .�; _ . .._. ... . . _. . . . . ... -�� .. . � . ��brs Urense Low dbes not appfy to an owner ol propeny �� - �'�� � � . '� � ��� � --� � ' - - � ��� � - � � � -- - � � '�who'6utlds or-improves�flieroon, a�d who�daas such `�� � � � - ��- � � � -- -����� � ��� � 1� - ; � � � = work himse(f provtded thor such improvements are not ; � ,� , .. � . ��. .���.. ... .� .... ... ..... . � ..:.. ... .. � Intendodoralfered forsale.N,hcwever,ihe buNding or � • ��� i . � � . ._._ . . ____ . _ . _.. . ._. . � � � 7mprovemenf�ls'sold wi�fl7n�one year oi�tomp7etlan,���ha ' �� - -�- -�� - - � "'�'� - ' � � ' �� � � ' I� ; '_� � � ; � � ownerbulfder w1B hcre fhe 6urdert.af provfng tha(fie d�d . � � � � � - � � �noT bu71d ar tmproJe for the purpose of sale.) � - � , .. . . i . , � , � . . . ,. _ _� ;,.�. ., . , :: > _t am exemp!under Sec. _ _ _::' I _'. . � '._ . . 6 8 P.C.for this reason ; � e�:r.•y . . � . ..�....._. _...... .. .. .. .__. .. . . _... � � ... _..__ . , �� �..� . _ ` _ ,, . �ate .. _ � _ _: . ___. __ _ _ __._... . Owner } _ __ _ _ _ ___ _ _. _. _ MSPECTOR'S NOTES \ ✓ _ .° f _ � ��- , . " , �l , _.. : - , {} � �,� ` . � . 4`��� � "�, 1��` . \ ... =�`��h. ��,"��.'�' .....