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1616A
WOR�ERs'�o,�PENs^T�oN°���ARAT�oN . APPLICATION FOR PLUMBING PERMFT � I hereby offirm dhat I hove�a certifimte of consent to self- 76A667A - . Insure,or a certificafe of Workars'Compensation Ir�surance, ..�'CE 817-fREV.10/91)� �-- - �- . - ' � � � or a cert f ed copy thereof(Sec.3800,Lab:C) COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑olicy No �CL$476F, Company"r_--AmPYicd1°t .. . - .. . .. . -. . ... .� .. - �� � �i�-i'���..•.. -_ . . . � �. . Ceriif ed copy is hereby furr ished�� � . BUILDMG � FOR APPLICANTTO FILL IN(PRINT OR TYPEI AD�RE55 � � �Certified copy is#ilad wiih fhe couniy bu�ld�n��inspeo- 20�Hd�1SW� Cl� dCl. tion department. . � NUMBER - - FIXTUREORITEM� ` � @ . -FEE � LOCA4ITV , . - Date�'1-��$¢� APPlicant �,e��t„�}q'� �-� WATERClOSET . . . -.. �. . .'� NEAREST � . . . �� . .�. `- ��CERTIFICATE OF EXEMPTION FROM�WORKERS'��- � ��� -�BAiH iU9 � � � r' cR055 Si. , ��.-. . ,. . _ . . �- ___.. - � .. . :�COMPENSATaON INSURANCE �� . - - . . - OwNee gOTld2Y'4Sd HOm25 �� (This sxilon noad no1 be compfafad if the-work involved 6y - SHO'vvER --- MAit �����-�- � " .ihe permih is Forone hundred doilars_�($106)or�less.) � _(., �tAVATORv � - � � � - •-'� aDDRess � -�1 - �" � �'�� �Y'D- �I certify ihat in the perfbrmorice of the-work for which this / � � --� - �- . SINK � CITY TEL.NO. ��permit is issued,bshall not employ any persnn in any manner l�i% ' _ . so as to bemme subject-to�ihe�Workers'�-Gompensallon Laws. DISHWASHER � � � •` �s -9 coNrancroR �,eavetton Bros., Inc. ��Da1e�� � Applicarti - C�OTHES WASHEa {y> �R� N^"CE TO APPLICANT lf, after mak ng_this Certificpte oi _ -��- �- -- _ = �����-�����' _ _ - -- ,. . . . __._�� _T.- .,� , � �� l ption, ou��shvuld become su6 ect�Ya the Workers` -:SWIMMING POOL RECfPYOR- - --- 7--� �� � .. � y I � � ' - CIT1' ' - ��, TEL NO. Co�npensation Provis�ons of the�a6or Coda,yo�m�si for�h- iawN svain�K�eR svsTeM �Irvin 92714�� 3-11� �. �, with comply wit6 such. provfs ons.or:4his-parmit�shall be - �- - STA7E -LIC. : �� deemed re�oked.� � . � WATERHFATER . . . . . _ /�. .,�-,.� llGENSE.NO.. . ' �-` �� CLASS ` � LICENSED CONTRACiORS DECLARATION -� � - DISTRICT NO. PROCESSED BY �" GASSvSTFM CIUTLETS R- � � -I here6y affirm ihaf l pm licensed ander provisions of Chnpfer 9 ...� . � � - �✓� . .,���� � Y� (commencing with Seciion 7000)of Drvision 3 oF the Business OUTLETSQVER - - , . � � . . �3A � �:�� and Professions Code;and my license is in f�Il force and�effect -- �-�sPE,SYSTEM - � . %v��/�,` �VALIDATION� � FINAL 191969 � r oa,Te f �ya License Number_ Lic Closs C36 . '��� �� . . � � - � : . . .- ..FINAL � � Leaverton ' 2-13-84 ey ��G�C^��,��t� C8 l.� Coniractor -Date �- � � F' . . � . . . . .. . . � _ �❑ .i am exempt under Sec� . .. .. . ' .._ � - ,.�. e�P.c.for rh�s�eoso� Plan checkfee � � ;"P �',bA . �� � - Date: -p�UMBINGPERMIT ISSUING FEE$� �:r1 � � Signarure . . . . . . . . � . . �. rY:.� o e� m�a�GJ_. - � . � . . _ . . � TOTRL FEE � -�r. �� � . l a 1 G�h,5U ? � � � � � -Rlan check-applimnt � � � � - � � - ;� SINGLE FAMiIY �� - � . __ , f.fj(��O u.. ^,: HOME OWNER-BUILDER pECLFtRATION ...... Nqme _._�_ „ ,� - .. -. —.--: .=:- -- -.— _- - ' �by affirm,thai I am exempt from tl�e�Coniroclor's-License .,.qddress ' - ' � � ���' J� L for-the-.following reason(Section-7031.5,-Bus+ness and - - � �' � . ,� - Professions Code):� � � � � City " ' � Tel.No. � - - . � � � ❑ I;as ownec bf the.properry,-�wiU do-ihe work and ihe' . � �� � .- . � : � � � � t . strudure is no�iMended or offered for sale(Section _ . � � . , . .. . � �'' 7044,Business and Professions Code). �� - . . , � - � . . � . � . � . - CONSTRUCTION LENDING AGENCY � . . � � � - � - � � . . I hereby affirm thdt fhere is a consiruction lendinq agency for . - � � � � � � . � � _ - . � :- tha performanc2 of ihe work.-for which ihis permit-is issued- . � . . �� . � � �� '"�� - (Sec 3097,Civ:�-C;). . . ._ . . _ . . . . . .. . �. .. _ _ . .. _. ._ _. _... �_ . .. ;��� � Lender's Name - --� . ' � . - . . � . . � . � . °�* Lender's Address ' � . - - I ceriify ihat I have reod�his�application ands�ate ihat�the �� � , .►� .. . .. . . -- - nbove informafion-s correci.I agree�o comply with all Coanly � - � - . ordi-nances and State laws regulnfing.Plumbing,ond hereby � - - - � � � . _ ._ outhor� e repre � tives of ihis County to enter�upon rhe � � � � - ; obov entiorted perty for'nspe tiort,purposes. - � - - . . . !�����(��'� SEE REVERSE FOR EXPLANATORY LANGUAGE �:� ' �e.�.r� a e .0 1 " `-- Signoture of Pe mittee _ � - . Da�e - � . . �� � . � � � . - � � .: I,'. , ._,-_ _-.s _�.��_.T�.� t_a:a���.�-�„ �n�r� �_�_�.a� �-�„' .__..s- - �"...,__. _.. ��_�.. �-. . .� _. � ��:-� ,� ���. - :; _ � !'�� _ - � � � t ��� � � � , v ���cc�a [y `� c^�4U a d w qy g . \ .` - . .. . . .. .. �- . .n �� .-..a ��"EJ ,m�- 4 1 . � �"� � 9:u �� x ts'-ay �sa�s.,m� , � � .�. � Q �oa� � � o �a � � � c� � - . . - ra .ry �w - U w-O �� ''9 u� �� .� �. � O �-� � p s» . �F. .. . . . - .. , � p;n � � .� q �i F. 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