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1615A
� - WORKERS'GOMPENSATION DECLARATION - APPLICATION FOR PLUMBI-NG PERMIT . �. � I hereby aff rm 9hai I hove c tertificate of consent�o selt �76a667A - - - � �. � . in5ure;or o cerlificateof Workers Compensaiion_Iqsurartce, -CE-817(REv.-.iDlAi)------ - . - � -- � - � � � - � or a ceitified copy-thereof(Sec 3800,iab.C) COUNTY QF`LOS ANGELES BUILDING AND SAFETY. Ocy No. &D84266 Company Gr_. American e�.�'.�� Cert fied capy s hereby furnished. � : �� _ � -� . FOR APPLICANT TO FIlL IN(PRINT OR TYVE)- BUILDING - . Certified copy�s f�led with the county b Iding�inspeo � A��RE55 � � . tion deparfmpnf. --����� -�--- �NUMBEk. � FIXI-LIREOR�iTEM � .(D� �FEE � LOCALIN � � .. oare. 9-1'i--.R4AaPli�ant i�vPrtnn-�-- . ` �WnTeRctoser. .. . �. . . . ,.�. � .. ._._-. . _ _ NEAREST . . . . � .CERTIFICATE OFEXEMPTION FROM'4UORKERS'- - ..-� . BATH-TUB. - - �� ,,.y CROSS�ST. . : - � COMPENSATION INSURANCE �. .- - - . � � OWNER - � '.� . (This.secTion need�nof be compfefed if ths-work�inqo�ved by � SHOWER . � � � ,.--- BOIICIBY'OSA Homes: ' fhe ermiT is farone hundred dollals-SI00.or less. - � - � ' N'A�� �� . . " . P I � . J . � ^ LAVATORY ^-(- �+ ADORE55 - � . I certify fhaFimthe per{o�mance ofi the work for w6ich ihis . � � � - - perm�if is iss�ed,I sholl not employ any peiiort-�in ony ma�ner- - SINK CITY _ YEL.NO. ,: .� . . .... , . , ' - sd�as ta beCome subjecf fo Jhe Workers'Compen$afion Laws: ---D15HWASWER- � - �� - - - - � - . CONTRACTOR'�LeaVO.C'�071-$YOS.� � � 6ate � �-� Applica-nt- -� - � , CLOTHES WASHER � � .Nr'TiCE TO APPIICANT If, after mnk�ng:th�s Cerhf cate of A�DR_ESS lb��]_ Hd�2 _-: - _ .-.-._ " € pt�orr, yau should betome subjetC io ihe Workers' �.-�. --SW�N�M�NGPQOLRECEPTOR-=�� -� � -� - '- . - C....�pensqhron pYovisions of fhe Labor Code,yoV musl forfh- ' LAWNSPRINKLERSVSTEM CITY I���. TEL_Np. _ ��� with comply�wilH-such-.provisionsor�this�permit shall be - S7aTE LIG - : deemed.re�oked: wnTee HeAtea „9 uceNse No. T91969 _- aass C36 -- LIGENSEDCONTRACTORS DEGLARATION � � - DISTRICF NO.- ��� ROCESSED 6Y GASSVSTEM OUTLEiS � ��.,: I hereby affirm IFiai I am licensed�ndar provisrons of Chapter 9 � -� .� � ��,y�',� � (commencing with Section 700Q�of�vision-3 of tlie Business OU7LE75Ovek � � - � . . �" and Professions�Code,and my license s n�full force and effed. ��5 NER SYSrenn - - FINAC ,/ ,/ VALIDATION - �' C3F> �. � r"'° �DATE ��`�'�e�?'"' � .' � �� � � - License Number 191969 4�c Class - - � �'� LQ dy L'tp❑� - ..� � . � FINAL yi„ .�fi�,�-��' � f � � Contractor L-.1�-$4 :. . ..Date �-2-1-3-�4 � . - --- �BY N/e//�'l ""° . .�- . � ;' . ❑� �I am exempl under Sec.;.. ��..... . .. ..... � � .. - . � � � � B.&P.G for 4his reason . - � � ► - � s�., Plan check fee ,� �S 1.�a � � . �Date; - _ PLUMBING PERMIT�ISSUING FEE$ �- . �j � " ��� � o m�� ,��. Sign�ture . . � . . TOiAL FEE ��j .'(� .. � . � . � � . .. . . . � Plan check opplicpoY . . .. � . ' � �I.�G�5.� . i, - - SINGLE FAMILY � . � m i ��� �' � :HOME OWNER-BUILDER DECLARATION" � Name - � �� - - , � " �' � � =6y affnm IhaYl am exempt.{rom fheLontractor's L.iCense � _ , , __ --- _- --- _ -- Y-�� � f�4F�` - L tor the following reason..(Section�7031.5, Business and -Address -. } Professions Code):. � �� - � � City - � Tel.Na � � � � . � �- .. �i.. � . . . . . . _ . . . - . . . I,ns owner of thepropeny,will do fFs work and tne .� sir�tlure is not iMended or otfered for sale(Sedion '. . . ... . ... _� � � _ . _ � . . 7044,6usiness aod Professions CodeJ. _ � � . � - . � . � - � ��' � � -CONSTRUCTIONiENDINGAGENCY - . � � � � � � - -_. .�_... - - . I hereby.affirm thqt ihere is q mnstruUian lending-agency for - � � .� � - � � the.perfor+nance of the�work fod.which ihis permii is issued _ � . � � . - . � � (Sec 3097,Civ.C.j. � . .. . .. - Lender's Nome - � � � � - � . - -� Lender's Address - - � � . � I cerlify Ihaf I have read fhis opplicatian nnd state thc�fhe . . - , � � above information is correct.I ac�reeio camply with all Couniy - � -� � . - � � ��-- �7 � ordinan�es and St laws regulat-ng Plumbing,ond hereby � � - - � � - ��� thorib� prg nt iv.'.af ihis County to enter upon the � - . - � _ . � . �� . � qbove�., toh,�,._ pertyfo inspection.purpo5es. � - � - -� . f �js �� SEE REVERSE POR EXPLpNATORY LANGUAGE ' � �C�t�- A d:��s�r--•7%:-r�� �� -�$�gnoture of Permiftee Dafe , . ; - . S. ,• L` �_.—_._ _ ._�. . � ,.-_., .�,r=. . _ .:�.--��y�. -� .�. „--..._._ ._��r.:�:F,.., ., .., _..:�. .. .. .- ._ _, � .,.�,..r:� ...-_.,, �.�.. .��-. �-_r-..•,.�-�-": .�'�� w-�":=� �t,'� ` �� �-cs � �; + .-_ - �.�D O�''O . ` - . . - . . 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