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1620A (9)
, �, , _- . , - - - - --_ � WORKER3'COMPENSATIONDECIARATION�� . APPLI�rATION- T�R �LUMBING PERMIT � , I hereby affirm ihai I have a certificafe of consent to self 76AC67A . � � - . . � insure,or o certificate of Workers'Compensation Insurance, CE en(aEV.io/al� � � � � - �,_�,�'' or a certified copy_�hereof(5ec 380D,La6.C.) _ ��p��yTY QF t�$ANGELES BUILDIY�IG AND SAPETY �cy No. 6084266co�,Paoy Gr. Ameriaan . c� � Certified copy�is here6y furnished '� � '1��� � � � � -FOR APPLICANT TO FILL IN�PRINT OR TYPE) g�ILDING . - . �Certified copy is filed wlfh ihe county boilding inspeo- � A�DRE55 $�4$_jjg �{ � . tion�department.. - . � -- - . NUMBER .FIXiURE OR ItEM C FEE ..LOCqLITY � � - - Date �2-1-3-84' �Applir,ant LeaF72It011 - � WATERQOSET . � -�NEAREST � � . � � � �i�`. -CERTIFICATE OF EXEMPTION FROM WORKERS' ,_� BATH 7U8 , .. .f,� �" CROSS ST. - - - .-'� -�� C6MPENSAifON INSURANCE �.. � .� � - OWNER- g4Rdg.rqSd HOID2ra (This section naed no1.be compiefed ii i6e work�involved by � SHOweR the ermif is for one hundred dollars 5100 or-less. "i-��- � . MA�� � - '�` P � � J LAVATORY � '� ADDRE55 7 '�� -. I<eriify thot i�n the performance of the wark for which tRi.s � � - - � _ - � � perm f is�issued;I shali not employ.�ny persdn in qny.manner � - SINK - � •"'� CITY� . ,.: TEL NO. ,;'; so as�o bemme subject�to ihe Workers'Compensation Lpws. . DISHWASHER � � - � - - � " coNrencToe Zpaverton Bros., Iric. . -0ate -.� - Applimnr.- . � . � CtOtHESWASHER . � > ..""' . . .�. _ ,: � � �CE TO APPLICANT: If, after making this Certificote-of - � � AD�RE55 167Z1.Y`�alE.-. _ . I hon; ou should�become sub ect to�the workers' . swIMMINc PooL RECEProR - . � � .. �- C.,,ipenso}ion provisions of-the Labor Code,you must forth- . . CITY � TEt NO.� _ �S . �wifh camply with�such provisions or fhis pefmit�.shall 6e � �AWNSPRINKLERSYSTEM- . . _ STATE �LIC. tleemed revoked. - � � � WATER HEATER - � t... LICENSE NO. ' ��' � CLASS � - ,���� - UCENSED G6NTRACTORS DECLARATION - . � . . �� � �Isieici rvo. � PRQ€ESSeo ev�- � - GAS-SYSTEM �- OUTLETS f� �`� ,.,y-� +'� � - �� --I hereby affirm ihat I am�licensed under provisions of Chapter 9 - - w' . �r�����, ��ommenang w th Sec�ion 706D)-of Divrsion-3 0{fhe�Business OUTLETS OVER - � � �-. � -p.,. ..and Profassions Code;-pnd my fcense�is in ful I force and effed. 5.PER SYSTEM - �� -A fINAL �,{ Np���Aj'��N �' ' License Number 19�-969 Lia C�ass C�3Fi � . C ''�' �ATE . " `� �y` . _ � `.._ r _. _. .._ .�.. .. . .. - - FINAL��i � ��� Comractor LeaVe'r�dR DateZl14—�3� � BY .. � �' ❑' I am exempt under Sec. �� _ � � � �� - . .. . . ._ . . . . . .. . � ..�. - 6.&P.C.for this reason � � . � � - -� � � . Plan check fee �-Date: _. - -pLOMBING PERMIT ISSUING FEE$ G��'G'� � � - - 5ignpWre � � , , . � �P - - � . . � TOTAL FEE ..�J�� . , . .�� t�Ei�,{t FI ,� . - . _.. SINGLE FAMILY __ . . � � PP. - � � . - � . .f a'c� o a� m rj . . Plan check❑ liconf �, t;� � � HOME OWNER�-BUILDER DECLARATION Npme - � - � � -� � , . � - . �.�n 5 p b,h(� - � ' aby affirm that I am ezempt from the Corttrador's License �� � ' --- � � �� - - -�. � L for the{ollowing reos6n(Secfion 7031.5,�Business and Address � ' � .. - - ... . �.��,�, � ��`,��CR 7 � � �Professions Code): - - � City - � - . TeL No.� ❑..I,as owner of ihe properiy;-will do.fhe work and fhe � � . . - � � - . � �'�� � 1^`U U- � -� _,� . structure is not intended or offered for sale (Sedion � � - . , � . � - . . ,� - 7044,Business and Pwfessions Code). . . -� -- - -.� � -�-- , . � CONSTRUCTION�LENDING-AGENCY . - �� � . . - � � `n _ I hereby affirm that there i5 a construction le�ding ogency,for � � � . , . � � -� � the peeformance of-'he work for which this pecmit is issued _. . � � � -.. ., - . (Sec 3097,Civ.C.). . . � . � . . -- . - � - . . Lender's Name � � - � � � � � � - Lender's Address � � � - - � -I certify�hn�I have read this applicarion and state that ihe- �- � . �► - -- � - � above information is correcG I ogree-to comply wfth al6Cbuniy � --- � � � -� �� -- . � - � - . � - - � � . - Drdinonces and Sfate laws reguloting plumbing,and hereby . �. � _ � . � - . . . - a ingrize�ep�e iotives af this County to anteF-upon the � � . . � . . . - _ - � - - -� - abo -menfio�ned roperiyfor inspecnon purposes- - � � � -� - - � r - SEE REVERSE FOR EXPLANATORY LANGUAGE ��f ��.c-,- r" ,�,� `x Sign fure of P rmitfee .- � Date � � - � � - � � � . �- � - . -- G � � � �_ Q �,'..- . .. .. ', ' � O in G� A� . � . - - .n -+ cqf� xi ' �G =e �+�r���1 �z� p� `:i *'"�^�h Z"�,� �r r�y��j0 " . . . - ��� � �r T ` � �9"�o�'�- j � D`G�'�. '➢'O �\Z �'fi � ��� "�� Q ` '� pr � \�i� u��A � � � a �, � � � F , � . . . , " .. . �p t yp„_ . 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