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�� .�^�,+KERS•�°^^PfNSAT�°N°E«ARAT'°" APPLICATION FOR PLUMBING PERMIT � �
� 1 he�'�:(irnt thot I have a certifico�e of consenr to seif �y,yy�q
inpr r��rtifitate of Workers'Compensalion Insurance, CE 8V�REV.10i81)
oi I..p py+f�y�eof(Sec.3&I0,Lob.C.� Cj�/r COUNTY.OF LOS ANGELES �BUIIDING AND SAFETY /
P�oli�c�f�lo�.^ r mpany .-. ,�I D . (
Cartified copy is hereby furnished.
FOR APP�IC.>NT 70 Flll IN(PRINT OR TYPE) BUILDING r
�Certified copy is filed with 1he county building inspeo- ADDRESS �$• � S .D/AHQ1l� a R �l�4
hOn departmenl. � NUMBER FIXTURE OR ITEM @ FEE
/ � O lOC>LITY �q,�o� ��}
oo�� 9—4 8� APPlican� ��i r���:� WA7ER QOSET caoss sr. .Q t+!
CERTIFICATE OF EXEMPTIQN FROM WORKERS' oj,y BntH iUe � I� O .
� COMPENSATION tNSURANCE SHOWER OWNER ��� �� �
(ihis sMioa nNd no1 b�cemplH�d 0 tM work Inrolwd by . n /
�h�p�rmit I�for ona hundrod dollan(SI00)or loss.) � iAVnTORv � ApD'RF55 ���� � �7%1��'�'�� V`� ✓4
I cerlify thot in Ihe performonce of fhe work for which this �
permit is issved,1 eholl not employ ony person in any mariner SINK � CIN ������-��� TEL NO. G' � ..
w os lo become subject lo�he Workeri Compensolion Laws. DISHWASHER 6
CI O CON7RACTOR 7'
Da7e A liconl CIOTHES WASHER
NOTICE 70 APPLICANTPIf, ofiar making this Certifica�e of G ADDRE55 g''g� �a^y��v� �v i
Exempfion, you should become subjatt to �he�Workers' SWIMMING POOL RECEPTOR dTY l.r� TEL NO.
Compensotion provisions of fhe Labor Code,you mvst fonh- LAwNSPR!NKLERSYSTEM �~ ` `/�N �� G�
wi�h comply with such provisions or this permit shall be . SinTE tiK.
daemed revo4ed. . WATER HEATER � LICENSE NO. d (/�[ C7A55 �i �t �
IICENSED CONTRACTORS DECLARATION tl � DiSTRiCT r10. PROCESSED BY
t hereby aHirm thol I om licensed under provisions of Chapter 9 � GASSYSTEM OUTlETS ,r ��
�commenting with Sec�ion 700p)ot Division 3 of the Business OUilET50VER
and Professions Co�n,andCmY I�pnu is in full Iwce and effetl. 5 PER 5v5ienn FINAL VALiDATION � �� �:�
� �7 V y � � ��/� DATE ��� �
Ucense Number'-��"�'?� lit.ClossS,.—.L "� O
�IAT��Vl '�� FINAL U..
1 Comracror Date BY �
� I am exempf under$et.� . 2�.'.� �L�.S A O��
1, B BP.C.for th�s reoson f'• • • . •S w
p� Plan check fee , � �
re:___�c:�Q'�0/
cJ Pll1MBING PERMIT ISSU�NG FEE S r O �O I •9 2 2 5 0 Z
$�an�i„rn —�1 _ _
TOTAL FEE �� m a^y 7�,j C�
Plon check opplimnt 0�.��-_�']
SINGIE FAM4Y
HOME OWNER-BUILDER DECIARATION Name
I hereby offirm ihot I am ezemp�irom ihe Co�tRgt�or's license p���p�s
law for the following reason(Settion 7031.5,B�siness ond �
Professions Code): . � City Tel.No.
❑ I,as owner of�he p�operty,will do the work and the
struc�ure is not intended or offered fo�sale(Section . ►
7044,Business ond Proiessions Code).
CONSTRUCTION LENDING AGENCY . _ ._ .. . .
I hereby nffirm ihat there is a tonstr�clion lending oqency for
the pe�iormance of the work 1or whith this permit is itsued , _ .
(Set.3097,Civ.G.). �
lender's Name �
Lender's Address ' . '
I certify thot I hove read Ihis applico�ion ond s�ate�that the ► '
obove informafion is correU.I agree to mmply with ell Counfy �
ordinances ond Siate laws regula�ing Plombing,and hereby
outhorize represeMaiives of this Counry to emer upon the �
obove-mentioned perfy for inspeclion purposez.
� Q c7 SEE REVERSE FOR EXPLANATORY LANGUAGE
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