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WORKERS'�COMPENSATIOt�`!DEGLARHTION �� �,��'�2� � G} � u '� � ' ! ����
s � �—��� ��.� ���`�AR�PL'F�`�lTION�F�7R�f�L�U1V�81R���PfRMIT � � , ��.:
�� i �raffirm 1ha�t I have�p certificate�oftconsen�to�.,self 76A667H '" � . ' � ." E`. , ���, ���'`'.
�'��' 'r a ceniflcote of Workers'Com ensation Insorqnce,� CE 8V REV 10l81)j • � ' �� -es � i � - y�'.
n,,, t�� P ; . . , �o . . - . ' A �h.i. �67 'N� :� �!Fv �
n *�o� _ertiyied co thereof(,Se.98 ,La6.C.) '�_ � A � GOUNTY OF105 ANGElES BUILDING AND SAFETY k '? �4 i °�
���'3--S�� " ( �
ii;'Pohcy No. Company � �.�5, ..� , . ' '. - � �� � .�'s'�'..��'�'� � i
l��'� .
��� CerYfied copy is hereby furnished. . -+'� BUIIDING
' FOR APPLICANT TO FILL IN(PRINT OR TYPE) �ia� �
�2� ADDRESS - i M�� � ��
ki� �Certlf(ed copy�s filed with ihe county building inspec- t� �✓ �'�� �. t i
NUMBER FlXTIJRF OR 17FM L� PEE ,i
�' ..lion deparlment. � '� LOCAIITY � .�- ' A�_ ��,
tC� . � . . � . � �. WATF_RCLC1SEi � �� d�'T �. i
,Dalg' ' Ap'plitant NEAREST Jyt i
„� � caosssr. L-�121�it�i� qJ�� �� �
� = CERTIPI C A T E O F EX E M P T I O N F ROM W O R K E RS' ; BATH TUe q� - t,� � '�
� COMPENSATION tNSURANCE � owNeR L� �� ��v�., '4
�� �SHOWER �- 1.I i.�i
'�.(ihis sactfon naed not be compleTed if the�wurk involved by'+t' `' .
� 41he permit is for one hundred dolters(5.160)or tassJ � iAVAiOev +,.�� �"� O DDRF.$$ i`j�� �.t/�ag y�$(,�• �� �� ,�
�a""•I certify�hat in the performonce of ihe work for whick rhis��� � � �T
r � SMK — � CI?V - �r TEL NO. ,}�``r
� �;spermii is issued,I shG��not employ ony person in any mqnner'- ��a� �C1 Gy?}2 (ji tiT C' ' ��..'
5 ,.,so as to become subject to�the Workers'Compensation Lows.�' , [ �
pISH W ASHER CONTRACT�R
: .1 Z. C.,. -�o i ��a. .��; .
'Date Applimnt �' CLOTHES WASHER AD�RE55 � / ��� ��
�NOTICE TO APPUCANT: I[, after moking this CertiLmte o4 � - - �D L�� ���� ����
� � l�Exemption; you should become subiecl.fo the Workers'�;�. SJJIMMING POOL RECEP70R /, � 4�
r CompPnsalion provisions of ihe Labor Code,.you mus�4orlh- ��Tv C,i+5_''4S�r3�3 �j/ TE�.NOL/�� � � a� _
LAWN SPRINKLER SYSTEM �f . �
�,�with comply w th s�ch p ovis ons o this perm t,shall be � , S7ATE y � / � UC. � . � .
deemed.revoked � �� - � � W'ATER HEATER � IICENSE NO J �l,.o C1A55 � _;
�, LICENSED CONTRACTORS DECLARATION - � � � O� atSTRiCi NO. Op,[t CE55E0 BY � j
s��''�5��;�I here6y offirm tha�1 am:licensed under prov sio s of Chopter 9��. 0 GAS SvSTEM OU7 (��` - . � �1�
s`��,tr��commencin � th Secfion 7000 of Division d of the Bus�ness `5`���y���R`�� � � 3
9 wi ) �� GUTlE750VER `j. . . . s �� �?g,'-��
���F'and Professions Code,and m license is jn foll fo¢e and effecC 5 PER SYSTFM
v FiNA� VALIDATION � I
�h;��Lice�se Number ��r�t`/�� Lic.Class�:t'"—�� � 1-' ("� DATE � a�,�. . , s; �..�.
I��f �,: �
� FINAL � � '�
� �.`Contracfor �l. �gsr. (a��. Date �r 7 ) �. ��:. BY . .,. � :�
' i � � ��. :� �
,��fj �'��� i am exempt u�der Sec. � � �� � � asg ;�
F y� B.&P.0 for thls reoson . � . � •.:
rx�: 1��, Pfan check fee t
.r' � F�, �Dote. . ; NLUM8ING PERMIT ISSUING FEE$ lQ -�� . .�, <
+� ; SignaNre�'�-.,�s''-��„-�...� 4;;, �' L�r� . �I�.
}� �':� � � TOTAL fEE ��.
e`h�, � � � � .
.. Flon check applimnr � � �
� SiNGIE FAMILY �i � � � .�
HOME OWNER-BUILDER DECLARATION � Name
� ' 1 here6y affirm�F�at I am exempt from the ConGacror's�l��ce�nsV �+". Addre.ss � r �
: Law for ihe f II.�.. --„'r �`=cyo^?„ • �
I ^ Professions Code)� ��,�^�^ y n�'J V �;� City Tel.No.� - . �1 U 9'4� + �, ��
i .
i,as owner of the ro ert will da 1he work and ihe �a
� 1 �� P P Y, �. . �� �;%o.m.• n a rj ;
� sirudure�is not intended or offered for sa�e �Section i
Y� 7044,8usiness nnd Professiong Code). � � � a m(�d.�Q '�
?(M !
g{..+��'t � WNSTRUCTION LENDING AGENCY . � . �, a ,�/��r�y u .�
7-��I hereby affirm that there�is a construdion lending agency for �
^ .'�rhe erformonce of the vrork for which this ermit is issued , z
`E;�Secp3097,Civ.C.). . � . P � f�I.1 r"�8 4 . ,. M1
�i �
;.Londels Name . .
� " j ` . �
r�" -�.Lender_'s Address . ' 4�
�� I cenify?hat I hove read Ihis opplirn.�er and sta'�tfia'the . � .
x �i above information is correct.I ayree lo comply with all County � . .
�� ��ordinances and Siate iaws regulating Plbmbing,and hereby ,
� ����authorire representoiives of this County lo enler upon the �
'��` i'above-mentioned property for inspeclinn purposes.
y v� ���� SEE REVERSE FOR EXPLANATORY LANGUAGE
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� �ignoture Permittee � D e
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