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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� _erti9ied co thereof(,Se.98 ,1a6.C.) ��'�? � A � GOUNTY OF105 ANGElES BUILDINCi PIND SAFETY k �T �s � � °�
�a��3--S�� �. �
ii;'Pohcy No. Company � �.�5, ..� , . ' '. - � �� � .�'s'�'..��'�'� � i
f��.'�, .
��y� CerYfied copy is hereby furnished. . -+'� BUIIDING
' FOR APPLICANT TO FILL IN(PRINT OR TYPE) �ia� �
�2� ADDRESS - i M�� � ��
�Certlf(ed copy�s filed with ihe county building inspec- t� �✓ �'��, �. t i
NUMBER FlXTIJRF OR 17FM L� PEE ,i
�'���.lion deparlment. � '� /y, LOCAIITY � .,�- ' A�_ ��, � ..
t C� . � . . � . � Z. WATFR CLC1SEi � �V d�'T �.. t
;Dalg' ' Ap'plitant NEAREST Jyt i
„� � caosssr. L-�121�it�i� qJ�� �� �
� = CERTIPICATE OF EXEMPTION FROM WORKERS' ;� 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' `' .
� "1ha permit is for one hundred dolters(s100)er 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. .��; .
ti `Date Applimnt �' CLOTHES WASHER AD�RE55 � / ��� ��
',:NOTICE TO APPUCANT: I[, after moking this CertiLmte o4 � - - �D L�� ���� ����
� � �t�Exemption; you should become subiecl.fo the Workers' SJJIMMING POOL RECEP70R , �� 4�
r Comp9nsalian provi5ion5 Of the Labor Code,.you mus�4orlh-�� �AWN SPRINKLERSYSTEM C�Tv �i+S`''4S�r3�� �j/ TE�.NOL/��,+ ' / 'n] ;._
�,�,with comply with s�ch provisions or this.permit,shall be � , S7ATE y / � UC. � 9 �' � �
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 sions of Chopter 9��. 0 GAS SvSTEM OU7 (��` - . � �1�
1���.Y��\Q—... . �. i
s'�,`�,tr.�commenung with Secfion 7000)of Division 3 of the Bus�ness�'; GUTLE750VER `j s � ry'�
�,��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 � � ��. :� �
,��fy �'��� i am exempt u�der Sec. � � �� � � asg ;�
F y� B.&P.0 for thls reoson . � � � •.:
rx�: 1��, Pfan check fee t
.r' � F�,l �Dote. . ; NLUM6ING PERMIT ISSUING FEE�y l� -�� . .�, < 7
+� ; SignaNre�'C.'�s'�-�..��..�....� 4;:, �' L�r� ' 9I.
}� �':� �" � TOTAL fEE a
� . . y�, ��. .
4�� Flon check applimnt � � ��t
� SiNGIE FAMILY °: � � � �
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� + �, ��
t.,
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 ,
"�se�pso9�,c� c.�. . P P, 1.1 9—.8 4 j
�; �
;.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 � ���� SEE REVERSE FOR EXPLANATORY LANGUAGE
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���ignoture Permittee � D e ;,_ .
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