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0785A (6)
WQRKER3'COMPENSATIONDKIARATION pppLICATION FOR PLUMBING PERMIT � I hereby,affirm that I have a certificate of consent to self 7gq887A . � insure,or a certifimte of Workers'Compensafion Insurance, CE 817(REV.8/88) � � � � � � � � � ar a certified copy thereof(Sec 3800,Lob.C.� � � � � � � � � � � Y � � y�,� � Y�- COUNTY OF L05 ANGELES DEPT. QF PUBLIC WORKS Poi�c No'� om n lu��.��i�c ��L . . . �Certified copy is here6y furnished. � � � � ❑ � � � � � � FORAPPLICAN770FIlLW(PRMTORTYlE) � BUILDING 2 b . Certified copy is filed with ihe couMy building inspeo- ADDRE55 e.J O �� � 7 t{� ,� � % �tion deportmenf. . . . . NUMBER F�XTURE OR ITFM @ FEE � � � ,�1n �,f � �ocaurv ��inL;w—d... r �Da1e �� `� AppliSaM ��Y Nf,i !r`�'�tt2_ . . wATER CtOSET NEqREST. . . . . � . � � .CERTIFICATE OF EXEMPTION fROM WORKERS � � BATH 1U8 � � . CROSS St . �, � � �� COMPENSAT�ON INSURANCE SHOWER OWNER� ��`. � '1� � ' -(Tfiis sec�ton n�ed nee b�eemplNed if fhe work inrolved by � . � .thp permfi i:for ons hundrod.dollar�(;100J or Ips.) tAVATORY DDRESS � � � � `/ � �� I cenify that in ihe parformance of ihe work for which this � , � � ��� � . - pe�mit is issued,i shall noi employ any person in any mqnner � SINK . CI7Y ���,.,�r� t�q�� 7Et,NOS'�y . so as�a become subject fo the Workers'Compensation laws. � j . � . � DISHWASHER� CONTRACTOR ,,r . �T ^� Dote. �ApplicaM � � � CLOTHES WASHER� ADDRE55 L NOTICE TO APPLICANL�If; after making this Certificote of � _ -GS t�t 9�`J � ���� � ' � Exempfion, you should become subjeU to ihe Workers � SWIMMINGPOOIRECEPTOR . ���}y - G Compensation provisions of ihe la6or Code,�you must forih- tqWNSPRINKtER5Y5TEM C1ry `� ""'"�� �L N ��asyG' �� w7th comply iih such provismns or �his permii sball 6e S7qh.. ca(� ���, �{[� � d�emed revoked. � - � WATER HEATFR � � ������ ���/Y d-� QASS ':7 C� � ' � UCENSED CONTRACiORS DECLARATION � DiSiitiC7 NO. . Mt D BY t hereby affirm fhat 1 om licensed onder provisions of Chapter 9 ( Gas 5v5iEM � Out�EiS (� � .�\\(\\ � �commencing wi+.h Sectian 7000)of Division 3 of ihe Business . OUTtET50VER . . .. . . � `��-- and Prolessions Gode,ond my litense is in full forca ond effact. 5 PER SVS7EM FINAL ^ �\� � � DATE VALIDATION License Number t-f'����3 Lic Class �/�•-2- � � � �. � . . . � FINAL� . .. A . Connacfor Yc� f�g� �—/7'z5 � BY �: � I am exempt vnder Sea � - � - � s.sv.t.fo�rh�s.eazon Plon check fee I � Date: . PLUMBIN6 PERMIT 155UINf.FEE� . .. ,Q � . . . Signature - � . TOTAL FEE ' � � � � . . .. . . . . . . . � . Plon check applicont � � � _ � SINGtE FAMILY - . . . � . . HOME OWNER-BUILDfR DECIARATION�- Name . . .. . . � � �� � � � �� .. . . . � I hereby affirm that I am exempt from the Coatroc�or's Licensa Address : � �� � � � � �� ��� - �� � Law fior the foHowing reoson(Section 7031.5,Business and . � �Profesaions Code�: City � Tel.Na � � . � - ��7 8,Jr A ❑ I,ps owner of ihe property,.will do tha work ond ihe . � � �a � � � �5 � st�udore is not intended or offered far sala(Saction � � � � . � ► - � � . . �� 7044,Business ond Professions Codej. � s e� �5� CONSTRUCTION LENDWG AGENCY � ���� � - � " � . � � � � a� o- ;� �`�n� � � I hereby aHirm fhat there is a conshuction landing agency for . � � the performonce oi�he work for which Ihis permit is issued - � � � � � � � (Sec.3097.Civ.C.). � � � � . U�,� 7'-8 7 Lendei s Nome � � � � � � - tende�'s Address � � � . I i 1 certi(y fMat i have read this opplicotion ond sta�e iha�Ihe � � � �� � � �� ��� . - � - above information is mrtect.1 agree to comply with all County . . ► . I ordinances and State laws reguloting Plumbing,and here6y � .. . . .. . .. . . . . . . authoNze representotives of this Coun�y�o enter upon ihe � � � � .� � atove ��emioned prope.rty for inspenion purposes. , SEE REVERSE POR EXPtANATORY LANGUAOE ��. �`1c�t-1�> �' / ���y-� Signa�ure of Permittae Date � � � . � .. ,_ ,. �. ... .. .. � . . , . �1 :._,� . . � + � �.. - . . .. � AFPkOVaIS DA7E ���;tiSFECTCa'$S�GrJATUk�E � ... INSPEC70R'SNOTES ... . ..'� � .� � � J;^ih�`tk-�UILU� L.CIArtAi ;)'. :'�� .� �, _�- ti- �.__' , .? . _ UItlfTL'R StA6 WOaK .. . .. -=_ �. ; ... - � b ht; �/ k��.il dn f. r 40.. •c�i � �'__ �_"' . i . .� s �t�w eitw��--r'�—a - -- � . �._. _ i��ens � �� r�, i on � � � ��� s n "�?t s p ,� 5R5 PIptNG .. . . :.�. �-- . .. . . Bvsin s cnd Yro/ �Co I h y ciij c r f���hrch • ' ��'�""-'- �-- - "�--'" . -"" — `- .roqu-res a p..�rnr,r iro cc,ns�rucl ali�, mp ov� deniaGsh. _ _�_- L71CSVi1Vr. .. ... , .._. _ , .. . . . � �__ ,_,: _. _ . ..... . _...�._"�, .... ._ . " o�re�amr any siroclure, pnor fo us lssuance,�also re� NKyT WAIER WcATER..... . . � �' '{ . . �..�'.. ... � '---.'- . �.�.,�� . ' 'ex f�he c,��lic�M fnr�uci� -. r.�i}io/ile e+si�ned slqfe- .... . .� . qu�r prr. � p'� J ____ -- ' PLU/i+'�7ihJG FiXTUkES ��- . ..-��_ . . .... . ..... ..�.... -�. . ....�� '�'mrnl fhot h�:�is f,.ensE;l�ur��onf lo fhe provision;ol�Ihe -_.—_-�-__-- ...._�. ..._-_."--�___ :. . . . . .. , .. .._.. ...__--____ .....-: GASTfSi.._......-_.... . � �... ... . '�. _ ..., . ..._. ._ .._ ' Conlrcrchurs�ticEri�La';.;FCf �r�r...r 9(cam`mencing wifl-i _ -� -- � ' � ' � Scc/ion 7Ub�;uf�b+vislon 3 of tY��9usiness ond Pro�es- U'I'�t1m1�C.'a„1f�ttD ' . � .. .�._ . � .. _ , _... . ;. __._ ._ .__� .. siUfh CUC2/er�fi1i71Lk iS exE t}FSefrfiESrfi rnR9 ilve aosis -'1 mP _ . �� - �-- 1—._- �.�.� �� , .., . � for�ff,� ol�grd A rri,prruo A y v��a' � ol-srcror, . . c� . . . ..„� __T - - � J031 5 6•c:n tn 6co'nf dur c, rmr!sub rcrs Ihe a II- vmn� - .�ktcr on _tronf. � . �.� . . , ' ', r Y r V ._. p•. �. pp .... .. - ------'� �. . . �- '.,-mnt ro o-aJ�l�,end�ry'af no� mo•e Yh five�hundred .__. .._. _. . ,. . .-. .._ .. --- -'_ ..�dollu s(55 UJ:. . .. - . ... �—�--- ---'..' � � _,i. s o,::ncr cf tl�,e pr�p�rr�wl�l do ihe war4,nnr) � _. __. __.. !1a�G5?RL4:_ . _�. _ ' � .. .;.. � ' . _. � .. . .. � . -... ,. ` "-,-,_.______ - � r�o��niended�oc>tfe�cd forso�e.� �.SA512 APFIiCVAt .� �� � - � Ihe s�u � re's ���� ,- _- _ _ _ . ...._,.._ . . .. .... ._ . .. . ... . :. ... ._.. . . ... .. .._ - . , - .,. � ��(5rc 7fi�#�H;isnilSsurrdProf� ' nsCodr. 7h��Contrar- .. '� .�.�--�—` �-�- -� ... }or's G�o�se t5w h;es not crpfy fv an ownar�a/piop4rtY I f . :. _. _.__ _... .. . . . . . . ._.__...- _.. _...-. `�.`_ .. .. _. . �. �.� . . . w�Ao bull:;s �, _ �. �: � : r mr��ni�m�o�s t'r,�rcon,��cnd�who�coex�such '� �� , _.., . . . �-. - _-----, __ .-____-_ �_. . . . .. . . ; � - , . . . ..,_ � _ � ��� ,� , � ��wark hlmself�rov;daJ�fAaf such irnpra�ememis or�.�not -.. _ �. .... ... ..; .. .. ' ... .. . ��� infen3rci•:nr Gff�e�!e�u f�r scfe.li,�tiowe4rr:the building or �. �� _ � �.�� .�. .-' �-. '. ._ ` ' _.. ._ . . _ � ��.� .. �-.. � ----'- rtvfFivYt�i�rr�rita.�erYl+rt�rchSaofp+ov��t`hre'the�d ����,�. �� '... . . . . ..._. . . ._. __... ._ . _._ ....._. .� : ` .tiM1e urpoie.ol s tc I ..,,, .. ��, .. :- r ; --^ nr roia � ',�. . � :.J.. .. . �..__. . ... . _.._..__.. ... ...�.:-. _, ...._.._...�.. �I-am ex�rn urd�r'S � ' � . ., .. . -p� �:c�.�- -- . _.--_.--- ---�------ -�. .—.....--`----------- ` ' ,_.__ ��... .� . .. ' '' .�...�.6&�F.C.fcr this ieason_.._-._ . �_ ' �,..;�.. `_� . ._ _ _ . . . . . __. _....� , . . .. ... ... _ . .. . . : .___. Go�_ �..__ -_.__: _-------_.. .. -_-;,.�.--- =----...------ �---�-' O�.tincr------..`----- . IPJSPECTOR'S NOTES _ _ _ :� ------ � � . . _ . _