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1621A (9)
WORKERS'COMPENSATIONDECLARATION � APPL�CATION FOR PL�UIIABING.P�ERMIT - �-� "' f hereby off'rm that I�have�a eertificate-of consent fo self �bA667a � � � � . � . . . �� � msure,or a cert ficate oF Workers'Compensation Insuran�e, �CE av(REV.10/81) -- � � � -- . � or a certified capy th�reof(5et.380d,Lab.C.) . COUNTY OP LOS ANGELES BUILDING AND SAFETY . ...- P❑alcy-Nb.-GRRd9F�,�Company f�Y ...Ailt('rTC;Bri .. . . . . . _ . . . ✓„�✓�--.: ,,�` . . ... . � . . Certified copy s hereby furnished. 4 I--I � � FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING " � ' ., � __{..'Cer�ified mpy,is filed with ihe county building in5pec- � ADDRESS � � `�fX tion deparimeN. . NUMBER FUCTUREOR ITEM ��+�� FEE �-�OCALITY �pfe .�_1���__siA .�APpliGant��L,�.'}S�er�"C1Ll � � �_� WATERCLOSET . . _ d �,.-. ._ -1�Sd1720[iC3 BdY ._ . -�} , � IVEAREST � . CERTIFICATE.OF EXEMPTION FROM WORKER5 � e�.c BAiH TUB � . �/� ---9� CRO$5 Si. � � � - - � ��� COMPENSATION iNSURANCE OWNER pOT1CIeLQSd HOitt25 � � ` � (7hissectlonneed-noi-becomple}ed�lf�theworkinvo�ved-by SHOWER � _ : , fhe permiT is for one hundred�dollors(5100):or fess.) � � C.-� - LqVn70Rv -�-" MAiL� . . -- ��` ADDRE55 - I�certify ihat in the performance of�ihe work for which this — .. . . . r p not empipy pny persan in any manner ' SINK . � � - � � ,�.,- - CITV .,.. - TE4.-NO. $33-21$� �. ',' ermit is issued,I shall .. . so as to become subjeci to�the Workees'Compensation Lows. � DISHWASHER �� � - - - . , . . . - - ,y "`.� �CONTRACTOR �a.FT�Y.t037� $Y`4S.��IY1C. . . Da�e � - -Appl cani � ' ' CLOTHES WASHER � �_ ' - Nr`TICE TO APPLICANT: If �after making'ihis Certificate of . � ADDRE55 _L6�721 H��.fl .. - � . f pfian,��you 3hbUld�betome subjad�Yo ihe� VJorkers' SWIMMING POOLRECEPTOR - -� , - �'. �(... pensatlon provisions 6f fhe Labor Code,you must forth- - CITY ... ..:,. TEL NO, " wtlh comply with such provisions or this�.perrnii shall. be �WNSPRWKLERSYSTEM - . -. , . _ - STATE �LIC. . �,� deemed.revoked. � � � � WATER HEATER � � � j,�, LiCENSE NO. -��" CLA55 -.��LICENSED CONTRACTORS DECLARATION. � � - � DISTRICi NO. PR4� . BY I hereby affirm thai I am licensed�under provisicns of Chqpfer 9 ` Ga5 SYSTEM' �.�""'f�pUTLEfS . - �;� +9 i �� � (commencing with Seciion 70Q0)of Diyision.3 of�he 8usiness - OUTLHSOVER � 'f�i����"�`-�°- � and Professions Coile,and my license is in ful I force and effect. - 5-PER�SYSTEM � � - ' A - --- on E� �'�t�f�f'd� VALIDATION � . � License�Number 1.919SQ Lic..Class E� � . , �,g ,>-_ Contractor r,E'avPrrnn . .. �. ��� . . . FINAL ,y}„��,,� � Dafe 2-��-$.[� _. . . . eY f//! � ., ❑ :. . . . . . . . - �� ,. -I am exempt�under Sec ygy -, _. ._ . . . . ... . .. . - �: :a�. - B,&P.C.for ihis��reasan . - . � . � ; - Plan check fee ,�, � pp,e� PI.UMBING PERMIT ISSUING�FEE$ - � � Signature. .. . � j � . . . . . . . ; . . � � TOTAL FEE �� �,� .. . . . ' . . .. � . .. . Plan check applicani � . � � . . � :>1 C)�,i � � . � - SINGLE-FAMILY � . . . . � � � . � � � HOME OWNER-BUILDER DECLARATION- � Name - - -� - � � � _ �;t F^ -a �+ a�� � . I xby affirm thal I am exempf from tHe Contractor's License �qddress - - � - �-_m��.{)f�4j(} !. i .ror ihe following reason(Section 7031.5,�Business and . � - � �� - - � Professions Code): . . ... .. City - � Tel.No. _ .: � - . . . . � . . ._ . - � _ . ... . ."��.o � jd,J i�;ti . l I,as owner of the property,will do ihe work and ihe ' � -� - �sirutture is not�infended or offered for sale (Section � . � � , � . . . ss� � 7.r c'�/-4 . � 7044,8usiness and Professions Code). . - - � -- � ' � - � � � T' � - � � -CONSTRUCTION LENOING AGENCY � � � � � . � � � � I hereby affirm Thai�there is-a-constr�cti�n lending�egency for � . . - - . the performance of the work for which this permit�is issued � - . - - � (Sec.3097,Civ.C.). � . � � � . �. . . � � - . Lender's Nome � - - � �� - Lender'sAddress- . . . . . � _ . _ .._. _. _..._ _ ___ .._. _... . . . - . . . . . _.. . . ',� Y certify that I have:repd rhis appli.cot on_And stdie that the �� � - ab ve Informqhon is correct.I agree to mmply wifh aIPCo�nty . � � - �� - -- � - . -- - ordinp ces and Stoie lows regulating P�umbing,ond hereby � . � -; autho ze repr ntatives of Ihis County to enfer upon the -� - � -- - - - � � �-- � ��- ----- -� � � �' abo meMio�re r ropert f r insped on p�rposes. � � � � - - -SEE.REVERSE POR EXPLANATORY LANGUAGE � � �'.�4��,�� �z-f�-�� Sign ture of Permiftee- �. Date . - . . .. _.. .... '... . . . . . '..- . -. . 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