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� '"°RKE"5"�°"^'E"SAT'°"°E«"R"T'°" APPLICATI4N FOR PLUMBING PERMIT ��aa, �
1 hereby ofFirm iha�I have a ceriificoie of consen�io self 76A667n .
insure,or a cerrifimfe of Workers'Compensalion Insuronce, CE BV(REV.IO�BI) .
or a ceriilieEi mpy thereof(Sec.3B00,Lo 1 /�� � COUNTY OF l05 ANGELES BUILDING AND SAFE7Y � �
Policy No.��Compony !�'�`^� �
� Cerf�iied copy is hereby furnished.
OFORP.PPIiCANTTOFItUN(PRINTORTYPE) BUIIDING S- f D
Cer�ified copy is flled with the coumy bullding inspec- - /+D�RESS
lion deporfinent. NUMBER FI%TURE OR REM p FEE � �
q ���Q� F� �[ LOCALfTY � �
�Do�e_l�.C�Y—GAppliSant v ��L�I _ WATERCLOSET �0 NEAREST .
CERTIFICATE OF E%EMPTIQN FROM WORKERS' ea7H TUB CRO55 Si.
COMPENSATION INSURANCE SHOWER OWNER r L� �
(This�«tion nNd nol b�complM�d if Ih�wodc involv�d b� ���
�h�p�rm8 ts for on�hundr�d dollan(fIDO)or lass.) lAVA70RV nDORESS �� -
I tertily thoi in ihe pa�formonce of rhe work for which ihis �� � lr��
permil is issued,I shpll no�employ ony person in ony mpnner SINK [ITY TEL.N bJ
so os to become subjec�io the Workeri Compensation Laws. , D�SHwaSHER
CONTRACTOR
Dote App�i[ont CIOTHES WASHER A�DRE55 � bG�1
NOTICE TO APPLICANT: If, oHer making �his Cartifimre of
E[emption, yov should betome subject 10 1be Workers' SwIMMING POOI RECEP70R �� q 'n
Compenwtion provis�ons o(the Labor Code,you must forth- QTY TEl NO � �)b6-<s
Wilh Comp�y Wilfl S�[h prOvisions Or �his permil sholt be �WNSPRINKlER5Y5TEM ' STATE ^�/�� IIC.
deen'IEd IeYokGcJ. WATER HEATER LICENSE NO. /(J(7 C1A55
LICENSED CONTRACTORS DECLARA710N otSTeiCi n10. r�tocE55ED BY �
I heveby aHirm thol I am licensed under provisions of Chopfer 9- GAS SYSTEM OUilE75
(commen[ing wifh Seclion 7000)of Division 9 oi 1he 6usiness - OUTLEiSOVER Q
ond Profesi�ons Codae,ond my Itcense is in full(orce and effect. 5 PfR SYSTEM FINAI � �/ IDATION � �
'/OS 7O� DATE //�`� a';
License Numbe.- lic.Class� � .
.�y�� . . FINAL (,).,
Controc�or ��]•�•wl� Do�e q_Z?' BY ��
�
� - o
I om eaempt under Sec.
B.&P.C.for fhis reawn � W
Plan check fee Q�-
Da�e: p�UMBING PERMIT ISSUING FEE S U (� Z-
Signaturo � . .
TOTAL FEE e7,� -.'__� 2 9.�I A �
Plan check opplimnt �!. . . . .5
SINGLE FAMILY
HOME OWNER�BUILDER DECLARATION Name "�� I ° °Z Z Jr O
I hereby affirm ihot I am exempf from Ihe CoNrac�or's license Addrets
low for ihe following reoson fSecrion 7031.5,Businexs and �� . � � • • °�L 5 U�
� Proissionz Code�: ' City � Tel.No,
❑ I;os owner oI Ihe property,will do Ihe work and the � �9�2�$� �
slruct�re is not in�ended or oHered for sale(Section , • .
7044,Business ond Professions Code). �
CONSTRUCT�ON IENDING AGENCY
I hereby nffi�m ihot Ihere is a conshuction lending ogency far � .
�he pe�formonce oi ihe work for which this permit is issued
(Sec.3097.Civ.C.). --
Lender's Name Na [�� , � � �
Lender's Addiess - -
I cerufy tho�I have�eod th�s opplicotion ond sto�e that the , , ' .
above informa�ien is corred.I ag�ee�o comply wiih aIl Coumy �
ord�nances a�d$�a�e laws regulo�ing Plumb�ng,ond hereby ,
auihorize represemo��ves ol ihis Coumy�o enier upon the . . .
abov -menrioned properly f r inspecNon purposes.
9 $ SEE REVERSE FOR EXPIANATORY IANGUAGE
�Sig orure of Perm� e ate
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