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1622A (9)
WORKERS'COMPENSATI6NDECLARATION �. � pP-RLICe�lTION-FQ�R.PLUMBING PE�RMIT . - I hereby-afFirm thot-1 hcve a ceriifimte of mnsent to self �bq��q - - . . � - insure,or o certifimfe of Workers'Compensation Insurance, CE BV(REV.70:81) .. _- . - �- . . or p.certified mpy_ther_eof�(Sec._3800,-:Lab.C.) � -COUNTY OF GOS ANGELES - BUILDING-AND SAFETY . - - � ���-� ._- Ocytvo. F,OR42HFi Company GY'. AIR2Y1Can '`'��,}...�y� _ Cedifiad copy is.here6y furnished. . � � �`� � -��� -� � � - - FOR APPLICANT TQ FILL IN(PRINT OR TYPE) BUIL�ING - - - Cer�ifi@d copy is filed with the-county building inspec- ADDRE55 35 2 �HdW�CWQOtl R(� tion deporiment. � � � � NUMBFR FIXTUREORITEM (�� FEE � � - . .� . .. . .LOCALITV .. . . � Date:��—Ad . � .Applieqnt-�T,pae�sartca�n-� � . WATER CLOSET _ . . � . . `� NEAREST � ... . .. . -._. ... CERTIFICATE OF EXEMPTION FROM WORKERS' , � BATH TUB � � � � ,,.�,� CROSS ST. � : ` �. COMPENSATION-INSURANCE� � � SHOWER � � � ',-.� OWNER j�OriC�@YOSd HOiI1C.'S ��- � � � '� (This section need not��e camplelel.if 1lis work involved by �• � . . . MAIL � � . -ihe permif is for one-hundred dollois(�100)or IesS.) �� �qVATORY ' . ���^� �.ADDRESS 2 � e '�. Y'. � � I certify that�.m the perf6rmance�of�the�wark for which this � � -� � - � - ' permii is issued,f sha�l not employ any.person in any manner � SINK - � -� �.� y�� CI7Y . ,.� TEL NO. �- �� �� - ,� so os fo�become subjecf to}he Warkers'Compensation lows; DISHWASHER - � �� - -� f'� .-- coNTRncroR Leaverton E3ros., Inc. Date � � Applicani . � � CLOTHESWASHER (.y '� �� ADDftESS � - � � N�'TICE TO APPLICANT: If, oftei mtiking�this Certificate of � . 1.6a2.L Hd.1.0� �-. . . �, � -{ ption, you shauld become �sub�ed to Ihe Workers' SWIMMINGPOOLRECEPTOR � � ; (., pensatlon provision5 of fhe La6or Cade,you mustforih- �p,WN SPRINKLER SVSTEM CITY - I �In 92.14 TEl,.NO. _86 �l Q' _.; with.comply with�such provisions oF ihis.permii sholl be STATE � � - - � LIC: - - . � deemed revoked. � � � VJATER HEATER LICENSE NQ �' CLASS � - � -LICENSED CONTRACTORS DECLARATION� � - � � � � DISTRICT NO. � PROCESSED�eY �, - 'I h¢reby a4firm ihat f amlicensed under provis ons of Chapter 9 GAS SYSTEM ' OUTLETS�� -- .� �j� �" �j�,���� � � �- - - U .Icommencin �fh Saction 7000 of�Division 3 of ihe�8usiness ' " � � J'�'"� � e. � � 9'^�� ) OUTLETS OVER - - - � � - - - ,,.a andProfessions Code,and-my license is in.full force.and effect 5-pER SYSTEM -FINAL �p p � YALIDATION � '' � _ ;-� DATE' � '�7-�GY� - ._ _ . � � iY �I.icense Number_���,�§o_ � lic Closs �3��_ : � FINAL �7 � Contractor r,Pat�Pr�nn � Dafe -�—.,1,3—$g . - �BY (�a..zC-�(�F�>� � � s � 3 . � . . . . . . .� . � I am exemp7 under Sec. --- ����- , � t8! ^ B.&P.C.for ihis reason. � . �. . . ► � - ,� , Plan checkfee Si nafure DQ'e� � � PLUM8INGPERMIT ISSUING FEE�$ . �}'_�� : � � � s G�� �,� �°? a22P. . . .- TOTAL FEE � - ' � � . . � Plan check applicant - . . . . . . � � � . -'p.6 � �� � �C� . - � SINGLE�FAMILY . . . � HOME OWNER-BUILDER DECLARATION Name � ' � - � � . � � ')-° � �ti�.'�J Q - 1� vby affirm ihat I am exempt from the Conirador's License - � � � . . . � � � .�- L ior ihe following reason(Section-7031.5,Business ond Address � - � . � . .. v 1(;(�,„�� Protessions Code�: . - � City � TeC Na. � - � — f217�-8.r� I,as.owner of the property,wilJ do�he work and the . . . . . strucfure is not�iniended or offered foi sale(Section � � � . '' �. . 7044,Bosiness and Professions fbde). � � �. -. � - � . ' - . CONSTRUCTION LENDING AGENCY - � � ._ . . . . � . - � � -. I hereby�aifirm that there is o mnstruction lending agency for � - - - _ _-� - , _ the�.performance of the work for which ihis peimit is issued � . . . � .. , ..- . - � - � (Sec.3097,Civ.C.). � . -� � . � . � - � -. �. _ . Lenders Name � � . � .. ... .. . . .� . . . . . . Lender's Address � - � � � � - I certify that I have rend ihis application and state tha[}he - - � � . . -�� . _ ... . - -` above infoomation is coorect.I�agoee to wmply.wfth-all County � . ordina�cas anclState laws reg�lating Plumbi�g,and hereby` . �� - � - . � - .. - ;; authori reprek tatives of�this County to enter upon ihe � �--- � - � --. ���� �. � - . - ,-' abov emiohe� operty for inspectwn purposes.� , _ �- - � ' SEE REVERSE FOR EXRLANATORY LANGUAGE � � . � :`� �` .�- ���/3�� � Si na re of P rmittee - � Date . . - - -- - -. � - � � - ,. G � .y ._ T. 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