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,: ,. ,. �. ..r,-... -,; _�--_ :, .,, -.- �.-_�r ____ _ . �� �___ _�-_ � WORKERS'COMPENSATION DECLARATION � APPLICATION FO�R PLUMBING PERMIT ��p�.� I hereby offirm ihat I have a certificate of consent to self 76a667A . . 3'y����, insure,or.�o cerfificqfe af Workers'Gompensation Insurance, LE 817(REV.IO/87) - - - - .. _ � - o�a ce�tified mpy the�eoi(Sec 3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P�olicy No. . __CompanY . —. . . . . . .. � . � .. � Certified capy is hereby furnished. � BUILDING ��R � ��; ❑ ' . FOR APPUCANT TO FILL IN(PRINi OR TYPE) �� ���{,4 y��>���r,p Certified copy is filed with the munty 6uilding inspec- � ADDRE55 Qe�� 4ibn deParf ent. NUMBER FIXTURE OR ITEM �i7 FEE . . � � LOCALITY� �`� ,i� wnrea aoseT � - -w lyf ia���r.�` ��..a.� Date�`„ � � �APpliGant���.���^" ��� � � � - NEAREST � ��-CERTIFICqTE OF�EXEMPTION FROM WORKERS' BATH TUB � � CROSS ST. � - COMPENSATION INSURANCE � OWNER � � (This section need nof be complefed if the work involved by SHOWee - - .�'�%)'" 'G�'.'-e�'��'!�- �_%?�'C=.�' - - the permiT is for one h�ndred dollore(�100)or IesS:) LqVAiORY� ADDRESS� �-c..� �+ - $��'J'`:j�`'�����iry� ���p` ��+r L certify tho}In��fhe perfarmante of ihe work for whfch this , � � � permif is�issued,I shall not employ any Persan-in any manner SINK � CITY ....�Qy�;,3 • TEL NO.� . so as to.become subject to ihe Workers Compenspfion Laws. DISHWASHER � � ,,�y . . ... CONTRAC70R' `.;� �L..,�Fry�„' j,-�y,� T Daie �- -Appl cant ' � CLOTHF.S WASHER ADDRE55 .��! ��� �,�,f1I _ f�'1.1�,��- N��i�CE TO-APPLICAN7r-If pfter-making ihis�-Ceril4icate of SWIMMINGPOOLRECEPTOR � - - � � � ' pt'on,�you should�6acome -sub�ect to�the Workers' CITY �r �� -` TEL.NO.���')�` l, �pensafiqn provisio�s,of fhe�Labor Code,you musf forth- �p,yyNSPRWKLERSYSTEM � �r� ���� � �� wifh comply wth such provisions or ihis permit shall be - � - STATE ��v� a LIC.�� �ry - deemed�revoked. � � - - �- � - - .uceNservo� �sc��`]�s�.�-- CLASs y�. WRTER HEATER � - � LICENSED CON7RACTORS DECLARATION - � DISTRIC7 NO. P SSED BY - GAS SYSTEM OUTLETS - � I hereby affirm thai I om licensed unde provisions of Chapter 9 � �� �"����y����.��.' �^I, .(eommenring with Section 7000)af�Dlvision�3 of the Business � OUiLEi50VER � ° � , 0 �ond Profes5ions Code�and my license is.in full#orce and effec}. � -SPER SYSTEM� FINAL �- ��'j onre / �-, �f"�-f VALIDATION ��; License Number �����Lic Class � � ;� Qt -, x J FINAL � '� Contractor/�����€'"�'� Date �". �� ��-� . BY � '�, .� _ ❑ � : . . . `�- !:,. I am exempi under Sec. _ e�, ,. :�d' , s.&e.G.for rh�s�eason— p�an check fee "" ' Date: - Signpture___ ^ PLUMRING�PERMIT ISSUING FEE$ ��, �, � , , � iOTAL FEE ,S"'(� � � - �Plon check applic�nt � � � - � � . SINGLE FAMILY � - . � - ��g Q 6 4,�P� - - HOME OWNER-BUILDER DECLARATION Name � � - 1� aby affirm that I am ezempt from ihe CoNroctor's License Address� � -- � � � . ��'�.e ro e � a,rj- 1_ ior fhe following reason(Sec�ion 703L5, Business and � �� � � � - Proressions Cdde): - - - � � City� � � - - �Tel.No. � � .j_�a'a 1 �j,5�� � ❑ -I,as owner of ihe property,will do Ihe work and ihe � . � �- � . � � - structure is not intended or offered for sale (Section � � � , _ � '''�•'` � 6.5 CS�. . . 7044,Business and Professions CodeJ. � � � � � . :: - CONSTRUCTION LENDING AGENCY . � � � . .. . .. .. . . . . , - � ..: f E�Z����3 �� ,: �I here6y affirm ihat ihere is a consirudion lending agency for � � - � .. ' � �- the perfnrmonce ot the work for�mhich this permit is issued. - � . . , � � . . . � . . . . . . . - (Sec�364T,�Civ.`C.J. - � � - . - � � .. � . ... � Lender's Npme � � . � - �Lender-sAddress- � . � � � . �- � I certify that�have read ihis applim}ion and stote thnt the , � . ►� , - -� a6ove informafion�is correct.1-agree to comply with all County � _ . .. - � - ' ordinonces and Sfate laws regulating Plumbing,and hereby � - - - autho'ze represenfatives-of.lhs County ro enter upon ihe .- . � -� � - ��`Zi'bn e-mentio d o anert for f n n��rpnses. `��� �� SEE REVERSE FOR EXPLANATpRY LANGUAGE ��� �� �� �� - � Signature of Permittee �� Date - - . . - - � . . . - � . cM�F�o�� -� "i �,e��, c,�,1 �a ��o�,G,c� ��,��c � T �� � �� ���� ����� �� '" � �`�; ��'�c � �� �`z �, ��t"` ���` �� �� �� i. c�ii�. r (y1��C� � �,�C {-� . rna� C�1 �-.��, aq�C3�� a . 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