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° WORKERS'COMPENSATtpN DECLARA'CION >swse�w � � � i hereby affirm that I have a ceetificate of consent to self cE evlz-eo) APPL.ICATI�N FO�R PLUfvIBING PERMIT `A° � insure,or a cer[iiicxte uF`NorKers'Compensa[ion Insurance,or � � � x certified copy thereof(Sec.3800,Lab.G) � y �"� u'�impany��'f� —1�� COUNTY OF LOS ANGELES BUIL.DING AND SAFETY Polic No. Cectifie�d Copy is hereLy furnished. FOR APPLICANT TO FIL�IN(PRINT OR TYPE) OUILDING / � � ADDRESS�- iL,r�C� 1'����t?£.t� /R+1�'Z � � C'ertified�upy is filed wi4h t e cuun[v hu�d' insp on �Nt1M6ER FIXTUFE OR ITEM • FEE ' ' (� �� IOCALITY � mj�+� � Dstee__�a �tf%t!.9pplic;:nt��"'� WATERCLOSET � �� � NEAREST BATH TUB CROSS SL f � 4 CERTIFICATE OF EXEMPTFON FROivi WOR. � S' � � � COMPENSATIONINSURANCE _ SHOWER OWNER ' LAV ATORY MAi L ..... .. ':.. ; (This section need not be compieted if the wock invoived __ aooqess � � ' �� by the peemiY ix fQg oae h�ndred dollazs (5100) ar less.) �� SINK CITY TEL.NO. � �, .� I eertify that in the performance of the work for which this DISHWASHER � a I r � - permit is issued,I shall not employ any pers�n in flny manner CONTPACTOR „ . l���� �� 7 —C � ". � so as to 6ecome subject to the Wbrkars'Coinp2nsatior.Lnws. . CLOTHES WASHER ADDRESS � �1 �Y ., �C � � � -�_—__.._ ...._--_ 1 � Dste � Applicant ___.___ SWIMMWG POOL RECEPTOR .1 � �4� � tiOTECE 1'O APf�LiCnNT.tr,after making this Cercihcate of — CITY 1 . � ' ��� TEL.NO&� '�d�''� � �� Lxemptiun, yoe shnu!d become sub,lect to tt;e 64'ur'r.e.s' LAWN SPRINKLER SYSTEM �. � STATE � LIQ —g Cad � Compensation provisiors of the Labor Code,you must forth LNCENSE NO.� �� , CLASS �"-3C,� = with com 1- �A�+th such WATER HERTER p) pzows�cns or this perm:t shal! be I F dexmed revoked. '; — D�STRICT NO. 4ROC�ESSEO BY � 't GAS SYSTEM OUTLETS �� � ��/' p�") LICENSED CONTRACTORS UECLARA7'[ON OUTLETS OVER � j� L>� t I he�eby affirm that I am license�unt3er provisions of Chapter � 5 PEi7 SYSFEM _.',. �..— _. ___.._ I FINAL � 9 (commenein�;with Section 7000)of DivLsian 3 of[he Has:- , VAL�DA-T��N � ness and Profa�sions Code,�nd my license is in iull force and _ -DATE efr2ct. yj'/--��•/�, � NAL LicenseNumber� Lic.Cfass�—�.. , --� Y �i.1qJJw'�--1 y (} t / y�.Cont��actorj�`_l��,_ _{L(_,�, Date�`��7,_. �� —__—. ____—_— ' _ - . 3 ❑ I am exempt from the�icensirtg requirements as I am a - Plan check fee i , � IicenseA architect or a registereA prof2ssional engineer � PLUPABING PEFiMIT ISSUlNG FLE$ , �-°' ��`w . ac[mg itt ¢:y p,e4esaeonat cupauii9 (Secfi�n 1�J52, Bus- _ — r - iness a�d Protessions Code). ,TOTR�FEE � � } � ;= L A'.; , iic.or Reg.No. Datc �-�Pian check applicant '�c� a fa s a� ,. � �� HOML O'NNI:R-BUILL�P,R D�CLARATION �- Name . �t�a — �4 . �� - Address ' . ... . �I hereby xffirm that I am exempt from thc Conirac±or's . �� '`�'- � � �'.Lioonse L'aw for the folko�ving ceuson(Sectiun 7031.5, Busl- � City Tel.No. 4" � ^ T V �.ness and Piofesions Code): � , - - A�{���.�'� . �;� I,a5 owner of the prnperty,am exctusively cmrtracting . � �� � - � �� with licensed contractocs [o conatruct fhe project . � - - (Section 70A4,Business and Professions Code). � .- - . . - CONSTRUCT[ON LBNDING AGI:NCY -� � - - � � _ �i hereby affirm tha# there is a constmcticn lending agency � . - �for the ucrformanec of the work foc which this permit is _. - -.�. - ;issued(Sec.3Q97,Civ.C.). _ �. -� � ;Lender's Name ._. - . . € � Lender's Address ._ �- � . - . � I:certity Yhat I Hava read this applicaCtmi and state that Yhe � a6ove informa?io.^.is ccrrect.I agree to comply witti a!1 Cou1ty SF:F,RF:V F'ASE FOR F.XPLANATORY LANGL*ACE ordinances and State laas regUlating Ylumbing, and liereby suthorize rapresen[a[ive5 of this Counry fo enter uyori the - �� nbo�e-mention r pect f:f i inspection purpoees. . r � ' �=�/- ignature nf Yermi e ate � ;:S z � � I�i����Cl 7'�(�:ii�C� . 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