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� k , -: --- _ __- . v�� �� =� �-� -- —� :— - -- �� WORKERS�.COMPENSAi�ONDECLARATION � APPLICAT10.6N�FOR PLUMBING PERMIT ���� I hare6y aff rm ihot I ho o e hficate of�consent to-self �6A667A . � � - - � in e o ert f ate.f Wo ke s Compensafion Insuranca, CE 8V(REV_10/91) � � � � �� ,���,� o�a cerrified copyqhereo4(Sec.3so0,lab.C.) COUNTY OF LOS Aiv'Cs€L€5 UILDING AND$APE7Y P❑ol cy No. fi0ft4)hfi Company C:Y.—�ILP_S1C��^,. . .. � .�. � � � . �-- ._,r. � - . _ ;. Cerhfled mpy�s heraby furnished � BUILDING � � +�, � - FOR APPLICANT TO FILL IN(PRINT OR TYPE) - ADDRESS . . � Gertified copy is filed w ih the,county�building inspet- � �_ _ . � _ - tion deparfinenf .. - � � NUMBER . FIXTURE OR ITEM C FEE � � . . �� _ . LOCALITY ]J),aliqQpa $dT � . .Date. -�-�_�z��_Z-Qn ApPLcani --���:��8}3 ._ . .� WATERClOSET . . r NEAREST - . . . . , -.... .-. . .-.. CROSS ST. �.. CERTIFICAIE OF.EXEMPTION-FROM WORKERS'� �,y� BATH iU0 � � � ,�. -"' � _ �� � - �� - - COMRENSATION INSURANCE ' �� � '� f- � � -- -�- ! OWNFR sHowEa — Ponderosa Homes (Tkis saciion naed nof be wmpleTed iF fhe work indolved b� �� - . •�- . . - : 4he ermp.ls Eur ona hundred..dollpts ;100�or less. � ��/ , MAi�� � . . ;; P � J J LAVATORY � �� -^`^ ADDRE55 ' - :�r I certify ihot in tFe�performance ofi the work for which this - � - � - � - - �� � � permif is issued,_I�shall nohempl�ay any person in any mnnner � � SINK� � - � � �CITY� . Ir'Vlne� 9Z7�.� TEL,Nq.�833-21$� . so as to become-subject ia ihe Workers COmpensafion-Laws. - � , DI,SHWASHER � �- y � �. �. � - - - #. ; ,- coNreaaoa �,eaverton Br�s. Inc. Date .. Applicanf . . � CLOTHES WASHER . . ...... ,. .. . � _ _ , `.. NI�iICE TO APPIICANT:�If after mok'ng th s Ce t ficate of � $WiMMING POO�RecePTOR ' '� � ADDRESS F pfion,-you should became su6�ec1 to the Workers' CI7V 7EL NO.�.� ' . C pensafion provis�ons of ihe�Labor Code,you must forih- - �AWNSPRINKLERSYSTfM �w th mply with such_provisians or ihis permrt shall 6e� - - SiaiE � � -- LIC. ;� deemed revoked. � � . . . WATER HEATER - ' - LICENSE NO. 19.�.9�9 CLA55.�� .C36� . -� ,,.LICENSED CONTRACTORS-DECLARATIOM - � - � �� - - 6'�� � � � oisieicT NO,._ � �P cESSeo sv -� .T4.,,. GAS 5V$TEM � OUTLETS f hereby affirm}hat I am licensed unde p av sions af Chapter 9 s„�� �- r� ' /"�,.'! � .- �. (commencing with Section 7000)of.Di s on 3 of the Business OUiLE750VER � � �-and Piofessions Code,and my license is in full force cYnd effeci. 5 PfR SV57'EM FINAL - ' / � VALIDATION �' `i . . � . . .,� � '� DATE ��oZ I ai h''' . . . � a:i License Num6e 7 Q���o Lia Class_� E3� �� ) � �� - `'�' � — . . . - f`p � ;�, � y .'�' .FINAL /� � Coniractor Tag�eYt0.11�- �ate. o_�,�n_on � . .. BY ��'f.i"�.eLu-� . . �' :-. �� � ❑ . . � . . _ . , . � � � � � � - I am exempt under Sec. � e�a_ i � .'. a.BP.C.for th�s reason - plan check fee �, �are: _ , �'� b 1;3 A -- -_ , � �PWM8ING PERMIT ISSUYNG FEE$ � "Yr� _ - . � � ' 5 gnaiure , - - � �� `+ � � � .� . � TOTAL FEE ff. "-�C� � - . ,��G.� a s w,��.�; .. ., . . . _ �.. . . � ..Plan chetk applimnt . . _ . . °�Q::� C� . � ��-.� j �Q J'.0 � .. ;.; SINGLE fAMILY� - � � . . � . . � � �� HOME OWNER-BUILDER DECLARP,TION -� � Name - � � " . � � � _ . ,_ , �, ��?,�{lc�J=� _ - I' aby affirm thai I am exemp�from the Coniractor's License . qddress. g � L or the following reason(Section 7631.5,�8usiness and . . . .. - ���i��-8,/{-. Proressions�Code): . � . . . . . .Giry . . -.Tel.No�. � � . . . . . . .. ..... � . . ❑ I,as owner of the properry,_will do the�work and the � .� � � � � - -� � : � - - - �s�ructure-is-noi intended or offered for�sale (Section � � - . � - _ � � , . ,� - � . .- 7044,Business 4nd Rrofessions Code). � . � - � . � - � -. � � - - � � CONSTRLICTION�.I,ENDING AGENCY . . . � - . . � � . . - - I-hereby affirm ihat 1Fiere.is a conslruction lending�agency tor . . - � . � � . . - ihe.performe._e ef!he work for wkich ihis permit is issoed .. - � � - . . � .__ . � . - �. � � --� :,, (Sec.3097,Civ.C.). .. . . . � . . . - .. . . � . � � . . . . . . : . . - -. . _. ._ . . . - . y`� Lender's Name � � � - � - � - Lender's Address � � -�- � .. - .I certify�rhot I.hava read this applimtion antl state-that the - � � -► � . . _� - � . �� above information is corzect,I agree fo mmply with all County - - - .- - � ordin nces�ond totelaws regulating Plumbing,and hereby � � - - . . � autR �ze rF;pres ntatives of this Counry to qnter upon �he � �- ��� - � � - - - � � - �- . - -- - . - - -� i� F._ abo -meiki .praper�y r inspecf on purposes. - � � - - - - _ �j�. �Ff��� .__. SEEREVERSE FOR EXPLANATORY LANGUAGE . - - . . " �nafure a Peimitlee/- - -Date � . . . . . . .._ - . - -. . ... . . . .. . ... . � . . - ��� �`�� � S ��� o��r � �j� � Z ;' Y c Ll P D. � � y en v,�.c�� . , ' ��, fi � R � �I�i����I� i � - ' .. ' ' ��, � � � � � '� � �,.,� . . . � , . - �ID.. - � ��� �(��� � �� . - . . ' � i ' � ��,�' I ��i��C� � , - . _ ..�b � � �r ��- �.I i 1��,;ro��� c+4 �`" �,� I� � k ;f � i � ; �i�� ,� "v ';�� � + a � I � q � . . i .. � Q�� _ .. .., . . � ( � . � � j��.P. '.. .. . I. �. . . ' . �... �s ' �., {� � .�.I � I �� . . . . . . . S. - �. . � I - ' i �. - ' . .. � g Z � I�' 1 � � � � ! �' � . - . . - . . �� a�: . . � . .. �. �, . I- � . . . ' . �� �, . �., . D �- . ' ; - . . � '. . .�. . . . ',- - .,- I � � ,� �� ', . � . � I . ', � - . _ _ . , . 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