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1617A (9)
� -WORKERS'COMPENSATIONDECLARATION APPLICATION �OR PLUMBING PE-RMIT � - @ �� I h reby affirm ihat-I haye a certificate of mnsent to self 76A667A � � � g i su e,ar a cert f cate of Workers'Compensation Insurance, Ce E3n(aEV.10/81) . : . .� • - . - . . � �: �q_�^�'�� or a certified mpy rliereof(Sea 3800,.Lab.C.) COUNTY OF LOS ANGELES $UILDI,NG.AND SAFETY ��yNo. 6084266 coR,Pa�y Gr, American ' �y . [ � Cedified copy is hereby furnished. . - -��` . �: FOR APPLICANT TO FILL IN PRINT OR 7YPE BUILDING - � �-CeYlified copy is filed with the munty fiuild ng.i,nspec- � � : � ( � AaDRE55 35�$�I3dW�SWOOd .RC�.� � tion depariment. - � . - :. . NU/N9ER � FIXTIJRE OR ITEM �' � - FEE �OCAU7Y � � 2-13-84 Lea�rerton � wnTeRcios�r Diamopd Bar �Date ��Appli4anf � _ . � NEARESi . .CERTIFICA7E OF EXEMPTION�FROAh WORKERS' ,-�� � BA.TH TUe � �., ��CRO55 SL. � - � �- � � � �COMFENSATION MSUR9NCE - - � — OWNER pOrid@YOS3�HIf18S SHOWER ' � �� �(7his secfion need no1 be completed IF ihe�work involved by - � MA` _ � �. . the pOfTit_IS�of one_�hund�8i�{�O��ars(�10��.0��055.� � � - �AVATORY �. - � - •--- � ADDRE55 ^ � . I certfy iftal n the performonce�of the work for which ihis � _ � � - - �permB�S Sued,I sha(I�nbf employ any persan in any manner � SINK� .. � � � �., CITY j�.�/2Me� �2714 TEL�NO. .$3.3-2�_$�� � - so as-to-become subject�to ihe-Workers'-Cbmpensalion Laws. DISHWASHFR - �� � � .' . � . � - . CQNTRACTpR LedV2,C�OTI��BY05.�� T[lC. . Date Applicanf � � , -CLOTHES WASHER - � � -"' ADDRE55 � � � . N^TICE.TO APPLICANT;.-If, after making this Certifiwte of � � � 16 21 Hdl.@" � � . �'� [ pi'on, you should become-sub�ecf fo�fhe Workers SWIMMING POOL RECEPTOR � - � �„� . - .. . . CITv _...,-. � TEL NO. �.� --f.... pensirlian pr�visions�of lhe Ldbor Code,-you must forth- �,qV✓N SPRINKLERSYSTEM � wrth mmply w Ih such provisions or this per�nrt shall be � - deemed reynked. - . � � �� WATER HEATER � j y„ ICENSF.NO. -�-91969 � � - C A55� . C36�'�� LICENSEO,CONTRACTORS DECLARATION � � � �� � oI57RICT NO. . - PRQgE55ED�BY �. .f hereby.pffirm thaf I am licensed�-unde p ovisions of Chaprer 9 GASSYSTEM-�� ' �OUiLEfS � ��"" � �� �����r; - �-.(commencing w}h Section 7000)oi Divis on 3 of ihe Business OUTLETS OVER � � . and Professions Code,and my license-is iq full farce and�effect, SPER SYSTEM FiNq� � VALIDATIDN � License��Number 1'97'9�9 � Lic.Class �36 � � � � . :DATE �-� ��. . � �,� FINAL,���// � Contractor LedVEYtOiI���� Date 2-13—R4. � - . .BY U/F�� _ � :, ❑ - . .. � . �� �. I�am exempt under Sec agg r' . . -. . _.. _.._.. . . . . . � � : .. B.&P.C�.for ihis reason . .. . . ..► �� . . � � Plan check-fee _, _ � - Date: pLUMBING PERMIT ISSUING FEE$ - � �. Signafure � �� � .�_� � ���,7 A . . _ . - , � � � -TOTAL FEE - ,�� � ` - . . � ��.;'� " �� . .;F_�, � � � ��.� .. _.. - �. � . � . Plan check applicant .-._.- ..-. .� . .-. . - !.� g y'���� .. " � $INGLE�FAMILY - � � � � . �-�HOME OVJNEB-BUILDER DECLARATION � � Name � � - � �� �� - � - �- � � �, I' by affirm-ihat I c m enempt from ihe Conirocfor's License � � � � � � �- . � .�i.r��j(j 4` � L. .or the followinq reason(Saction 7031.5, Business ond Address . _ � , �,°'��' � _ :, Professions Code): - � � - - - City � � Tel.No. � G,��d`<`'��. � � _ . . . �..y I;as o.wner�of ihe�properfy,will-da ihe wnrk-and the . � . . .. . - s7ructure fs not--inieniled or offered for sale (Section �� . . . . � ,, - � . .-.. � . - - ��� . . 7044,6usiness and Professions Code�. � . . �� �� -��-�- - - � � � � � � � CONSTRUCTION-LENDINGAGENCY� - .' .� . - . - -- " -- -�--�� ---- - - �` I hereF�y affirm ihet there is a.tonstruct on lending agency for . � . . � . - .� - -_ � Rhe perfarmar,ce cf-'he work for which ihis permit is issued .� � � � . - . - � �- - - (Sec.3097,Civ.C.). . - � .. . . . . . . - � , . Lender's Name - � - �� - � - ' � � . - - . Lender's Address . . . . - . . �_ . . _ . __._, . . ` _':-". ... .- �-... � , I ce hfy that I hpve read th s application and slate tha�ihe - � - � � - ;� . abo e in{ormafion is correct J agree_to mmply wiih all CouNy. _ -- � � � � - �- - - - - - '- -'' - . � -� � - . . ordmances�and Stpte laws�regufating Plumbing,and hereby � � . . autFoNz represej+i 'ves of this�Counly ra enter upon 1he � � ' � - � � -� - , 6ove- entiane$,p erty fo i- pecfion purposes. � - - � . � . � � � ��. - � .- r - -y �� . SEE REVERSE FOR EXPLANATORY LANGUAGE � . . _ ... . . &/�,.�,, - . . . . . . . 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