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WORKERS'COMPENSA710NDECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm thot I hova a certifica�e of consan�to self �yA�hq ,,
insure,or a ce�tificate of Wwken'Compeneonon I�surance, . CE Bt7(REv.�Oi6�) -
w o cer�ified copy�heraof�Sx.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �
P❑olicy No. Company -
Certified copy is hereby furnished. '�
QFOR API'LI�ANT TO HU IN(PRINT pR TVPE) ��,NG I S A :
Certifiad copy is filed with Ihe coun�y building inspec- ADORE55
tion deparfinent. NUMBER FIMURE OR ITfM � FEE
�ocaun �. {
Du1e AppliSant wAIER CL�Ei - ��T
CFHi1FICAlE OF EXEMPiION iROM YJORKERS' B/TH TUB CRO53 ST.
COMPENSATION INSURANCE SMowER pyy�p�� i
(Thb t�cflon nead nof bs wmplef�d if th�work inrol��d Iryr �i
fh�y�rmlf is(er on�hundrod dollan(5100)or le��.) v.vqtortr q�
' I certify�har in�he peAamance of the work for which this � �
permir ia�nued,I ahall nor employ any penon in any monner `�NK CiTv � iEl.Np.$ .
ao w to betome aubjec�ro the Workan Compenwtion Laws. , �W�� �
CONiRACiOR
[Iut p ' � CLO7ME9 WASHER ,
NOTICE APPLICANT: If, uftar makinq rhis Cx�ifimte of �� .
Exemption, you should beeome subjeo ro rhe Workers' 5���'���PT� �
Compe�wiio�provi�iom of fhe La6or Code,you must fwlh- GtTY lEL NO.
with comply with sucA prorisions pr thia parm7t shall be ��SPItINKIEG SYS7FM ,
SiA7E lK.
. deemed revoked. wni�re Hentfle ii�rrs�wo. cUss ,
11C�NSm CONTRACTORS DEGIARATION qSTRICT ND. SSEO BV
I hereby uffirm Ihot I om litensgd uqder prorisions of Gwpier 9 �S�T� W TlEiS �/Q �
(mmmencing with Secrion 700D)of Division 3 of�ha 6usiness O OVER �p �' �
and Vrofeaion�Cpde,and my literua ii in fyfl force qnd effM. 5 P�ER�STEM � �'
pA�� VALIDATION 0 i
Licen»Number lic.Clcra pp �
� �
FINAL O J
Conhnctor Date B� V S
� I am eaempf under Sec. � N ,
I8.8P.C.fa�his�eoson � 2 :
I Plan eheck fee
ow�e:
Sig�w�ure PIUMBiNG PERMIi ISSUING FEE s p e
TOTAL FEE
� SINGIE FAMILY Plon check appliconr f� J�,�l A i
HOME OWNER-BUIIpER DE0.ARATION Nome ryA #• � • • `$
�hereby nRirm thor I om eKemp�from ihe Conhvc�oi a license �/ n � ,
Low for the follnwirg renx��(Sxrti�n 7f1i1 S,B�ninea nr.d �d�� f V � • �2 Z 5�
Profeu�o�s Code): � Ciry Tel.No. •2 2 5�� '
❑ I,az owner of rhe propany,will do ihe work and Ihe . ro �•�• �
structura is not imanded or offered for eale �Seclion � � ' 0 2 0 3—8 4 �
7(Id1,Bueiness and Profmsions Code�. �
CONSTRUCTION LENDING AGENCV . .
I he�eby affirm thqt there ia o conslruclion lending agency for i
tha perfwmance of the work for which thie permi�is issued �
(Sec.3097.Civ.C.�. �
1
Lender's Name �
lender'c lyddress . .
I cenify rhor I hove read this applicetion and sio�e iha�the ,
obove iafamalion is cwrecl.I agrae ro comply wirh oli Coun�y
ordinences ond State lowz regula�ing Vlumbing,and hereby . �
authpri:e represe�WNres of this Counfy to enter upon the �
above-menhoned p�operty fo'i�spection purposea. '
SEE REVERSE FOR EXPLANATORY LANGUAGE
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