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1608A
. WORKERS'COMPENSATION DECLARATION - APPLICATION FOR�PLUMBING PERMI�T � - �� I here6q affirm-ihat I have a ceriificate vf consent to self ��yqby�q . - - - . � � insure,or o certificote o4 Workers'Compensalion Insurance, CE 817(REV.10/811 . - � � . � - .� or a�ertifiad copy thereoE(Se�.3900,Lab.C.) - COUNTY OF LOS ANGELES BUILDING AND SAFETY ��y No. 6084266 compa„y Gr. American : � Certified copy is hereby furnished. ����' - --FOR-APPCIC.4NT-TO FILL IN(PRINT-OR NPE}--� BUILDING . - .. . - ' �Cerlifis:d mpy irfiled wilh the counfy building inspeo- � . ADDRESS 3rjrj9 Hd .� fion deparftneni..-_ � - _ NUMBER� FIXTUREOq ITEM � FEE [OCALITY - �ate .2-3-4-84 A,pplicani. �. LedVEEtOri . •�" WAiERCLOSEY . -� �-'� � - .. .. . . .. . NEAREST � - CERTIFICATE OF.EXEMPTION FRON1 GVORKERS' �, BATH TUB � � . . /� --� CRO55 ST. � � . ;:�, i� - ��-- COMPENSATION-INSURANCE-- -. � � � � OWNER �OI1C72YCiSd. HO1112S - (TNis aetfion n�ed nut!s�^,omplelad iE tha-woAs-invclv�d�6y - SHOwER � the permit�.is�for one-hundred dollars(5100)or less.J � � �,[ . iqvaiORY � - qooRe55 �q . � I cerii4y that in ihe perforrrante of ihe work for which this _. ... � - - � � . - . � permd is�issued�,I shall ndtemploy any person in ony manner -SINK - - � � .--� CITV - , TEL.NO. ; so as io become subject ta ihe Workers'C¢mpensotion Laws.. . DISHWASH[R � � � - - � � � . ; . _ � - �� ��� � CONTRACTOR Leaverton S.:COS.� ZI]L`.� �� -�� Dafe � Applicant � _� - CLOTHES WASHER - .Y� qD�RESS � � � � . P' �CE TO APPLICANT:-if, affer mpking fhii Cerfificate of , � � � - �-6�21 Hale-��. . E tion, ou should become -ub'ed to -iha Workers' SWIMMINGPOOL�RECEPTOR � . P Y I CITY TEL.NO.- s r Com ensafion ov'Sions.bf iFe Labbr:Code, ou musl forth- ' P P� . -Y IAWN SPRINKLER SVSTEM . . . with comply wth such provisions or-ihis permi} shall be STATE � � -LIC. ��- deeme.d-revoked. �. . . �.. . - WATER HEATER ' �� /� ,.--, LICENSE NO. '"' CLA55 . ' . LICENSED COMTRACTORS DECLARATION -� � � �� � � �`� DISTRICT NO. � � f-PROCESSE� � � � �- _ -- GA55YSTEM � OUTLETS � '""' '� I hereby affirm ihat I am licensed unde provisionsof Chapter 9 � ' ��;'�� �''�,��� � .�-' (commencing.wUh Sedion 7000jbf Divson 3.of fhe.Business OUiLET50VER - , � � �° '� and Professians Code,and my license is in full fo�ce and effecL 5 PER SVSiEM �� � � FINAL � � � �;�'s. ' f -- oatE �r���c� VALIDATION License Number - 1 69 Lic Class (s'��� . . . � - ' � . . � . _ . � � . .. � . . .. F�NAL � f� : Contrapor LeaVQ�QI7== Date�2-13—R4, � � . � BY � � . . . � ' ❑-I am exampf undeP Sec -��- � -- - - � - - - � � � ,��,� . __ . . . _ . sog �� B.&P.C.fo�fhis reason � � � � ► � ��. Plan check fee m ; . -Dafe: . � ,� � � PLUM8ING PERMIT ISSUING FEE$ � ._' .. . � . . �.�i (�tA�� �� . �.Si nature � _-- _ � TOTAL FEE S"� .,�.a�� p a �,.5 ;I . 9 .. ._ ._ . ._ . .. . . � . . �I � - SINGLE FAMILY - Plan check pppliwnt � - � � � � �+�p � ��, �G�. � HOME OWNER-BUILDER DECLARATION � .Name .' - � � - � - �� � - � � . � Y ��� � I by aHirm ihat I om exempt from the Con}rodtlr's License . .. . . � - � ' � �J��Jf�'-% -Le... for the following reason(Section 7031.5, Business and Address -. � _ -�� Professions Cade): � � �� �� � . Ciry� �� � . . � TeI.Na � �. ._ .'�e�-.� �j"�t�� . �❑ I,os owner of ihe property,will do ihe work and ihe .. . � � . . -. .. � � - � - -� �-siructure is not intended or offered�for sale (Section � _ _ �, . . . 7044,Business.and'.Professions Code). � . . � - � � - � ��CONSTRUGTION-LEN�ING AGENCY � � � � � - -�� - �. . �- . � � - I hereby qffirm thai-fhere-is a consiNctiqn lending agency for � . � . . ' � � � - � - - � � ihe performance of�the workfor whick ihispermit isissued � . � ' � _ � (Sec.3097,Civ.C.). . - .. . . . - . . . Lender's.Name _ � . � � . . - � Lender's Address - � � � - - . . above information is correct.I ac�ree to com�nd�state ihot ihe _ _ .. ,� ._ _ _ . .. ._. . . - - I certify thai I have read this application - ' ply with all Coun�y . � � ardinpnces and State laws regulafing-Plum6ing,and-here6y � . - � - - - _ � a�fhorize representatives af ihis County to--enter upon ihe - � .- - _ . _ - . . - � - ah e-men� �-praperty for inspeclion purposes. � � � . . /� ��� � SEE REVERSE FOR EXPLANATORY.LANGUAGE �i<�`�-C.c� �^�',�-r.,_. .�?�0��`�' Signoture of Permittee Date � . . . � - � � q � c � �, c, � � o �, � � � � � . �eZ. 2 � ,`�'-,� `� � �z �rn�. =o���. 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