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"'°aKERs'`°"^PE"5"T'°"°E""""T'°" . qppLICATION FOR PLUMBING PERMIT � I hareby�offirm Ihol I have a certificate of conzent to eel(in• �76A��A�4�87 . , , . � �sure,or o:e�lifiFate af Workers'Compensation Insurance,or o CE B V(REV.B/86} - � �� � � � � . � . � , � .cer��fiedr.opy ihereof(Sec.3800,Lab.C.) �- , . . , � � � . �� Policy N�.��_Compony COUNTY OF LOS ANGELES pEPT.OF PUBLIC WORK_S/ ` . � CerfiJ�qd�Sj�y is here6y furnished. T � � � � � FOR APPIICANT TO FILL IN(PRINT OR TVPE) ADDRE55 .�� Ceriified copy is filed.wilh Ihe county 6uilding inspection O � deporiment. �� , . NUMBER . . FIXTURE OR ITEM � FEE �OCAUTY �� � WATER CLOSE7�TOILET) 2 Da�e�� Applimn� � � NEAREST . � � � '� CERTIFICATE OF EXEMPTION FROM WORKERS' � I BnTH TUe CROSS SL ,.. � �' .COMPENSATION INSURANCE ' � � � SHOWER' � ' � w OWNFR' Gt . . �� (Thl�uelion nNd nof b�eemplet�d if tM�work involvad by ,' Mq�� ' }ho po�mit Is for on�hondrod dollan(SI00)or loss.) � � � IAVATORY � � � � � � � ADDRESS � m,C --���� � � �� � � � � � I cerUfy Ihot in ihe performance oi�he work for wfiich ihis per- SiNK � . . . ..'.. . . mil is issued,I shall noi employ any person in ony manner so CITY TEt.NO. � os fo k»to iub'ecl to fhe Workers'Com� nsation Laws. . DISHWASHER - . . CONTRACTOR Dofe � Applicont � CIOTHES WASHER� . qpDRESS � - NOTIC TO A IICANT:If,after cking ihis Cenificate� x- � SWIMMWG POOI RECEPTOR � A � � amption,you should bemme s�6jec��o�he Workers'Compern CITY, 7Et.NO.7�5� �. � safion provisions of ihe Labor Code,you must forihwith mmp- . LqWN SPRINKLER SYSTEM �- � �� � � �. Jywith such provisions ar this permit shall 6e deemed revok- � STATE LiC. �_3 ed.� � � • ��� � , . � WATER HEATER LICENSE NO. CLASS � � UCENSED CONTRACTORS DECLARATION �� �� DiSiktC7 n10. PROCESSED BY �I here6y affirm thot I am licensed onder provision's of Chapler � GAS SYSTEM �� � OUTLETS - J� � � � 9(mmmencing wilh Seclion 7000)oi Division 3 of Ihe Business OUTLEiS OVER � � and Professions Code,and my license is in iull forre and ef- � 5 aeti SvSiEh� FINAL /,/ VAUDATION d fecl. ^`, , .. c 3.6 .. . .. z � DAT�/y �� ' � U Licanse Number �7�?�� Lic.Class � � �� - FINAL - � . ,� -', Conirodor �Dat . � � . BY . O ..❑ . . � � � . . U �. I am exempt under Sac. a B.BP.C.for this reasan�� +� Plan check fee � � � . � z ��� � ' �� �� / pp1@�� . �-PWMBING PERMIT ISSUING FEE S � � � � . � . Signalun .�/.ti1.DN�' . � . . , �� � .� . . s . � ~'� TOTAL FEE �O 9�G A � SINGIE FAMILY �(• • • • •S ' HOME OWNER-BUIIDER DECLARATION �� Plan chetk appiitant _. .�. . • I here6y offirm thot I am e.empt from the Conlractor's ticense Name � � . . . � . - . � . . � ° '3�J n . . . 'Law for the following reason(Section 7031�.5, Business and � � � - � ��- � �� ?rofexsions CoJej: _ � � - nJd�rss � � - -���',�u F � I,as owner of the property,will do the work and the City . �� Tel.No. � O a� B—8 S ' � structure is nol iNended or offe�ed for sale�Section 7044, � . _ . , . , . , . . . Business and Proiessions Code). . �, � . � . � � ► . � CONSTRUCTION LENDING AGENCY � "' � � -"- . � � �� � � � �� � � I hereby afFirm that thare is o construclion lending ogency for � � � � . � - . � the performance of the work for which Ihis permit is issued " �:� � � . � � ` � � � ' ' ! � (Sec.3097,Civ:C.). � . . . . Lender's Nome � � � � � � � Lender's Address � . � . . . : . ' � � � � � � . I tertify thot 1 hove read�his applicotion ond slote that the � � � � � � �. � ► � - � - � � - -� "� -' ' � � ' obove informotlon is corred.I agrae to mmply wilh alfCounty . � . .. ordinantes ond S�ate laws regulatin9 Plumbing,ond here6y - � � - . . � � � �� � � � � � � � authorize representatives of this County 10 an�er upon the � � , obove- tioned properry ior inspeUion purposes. � � � � � - � . ._ . . � . � SEE REVERSE FOR EXPLANATORY LANGUAGE Si�nature df Permiltee. Dale � , . � ' � ,' � � � , � / .' , t , . , , . . . . . . , . . �,\ � . .. � .. �t C � � S L) � 2] G ao z � a � o a n o z , -yi ai � r- -+ ; ` �n �n c� m � m 9 x � ' � . v y . n -y1 G� m -Zi Z �9 y v , ' � ." :� � Or = T = ,. G� � � O O m . m ' � , T c � z o a m t� a � .. . . j� . �, ' m V� 9 � 7c m �- ' , . � O , n .; . + -i , . o 0 O a � , � . _ r n m . `�J � , � , � , � . ... . . , � N , i N . , � � � - , � - t - �.� 9 ' - f . 1 y i y . ' ' . �,;'.� i ; . - ;.� � . D . : A m I _ ' ,... .. . " _ I � • i � , ; N . 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