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1372A
WORKERS'COMPENSAT�ONDECLARATION APPLICATION FOR PLUMBING PERMIT � � I he.e6y,affirm tho�I have a ce��ifico�e of consent ro self 7gp5g�p insure,w a terlificote o(Workeri Compenaation Inauronce, CE 81T(REV.B/88) - � - � � -� . � � � - - � - � or a cerrfied copy�henofS�Sec 3800,106.C.) .. . . � . P❑oUcyNob�[A399�_�oinpany5�'fl �� COUNTY OF LOS ANGELES DEPT:�,OF` pUBLIC,WORK3 CerYfied copy is hereby furnished: 1�� �,�.,,q ' fOR AVDIICANT TO Fllt IN(PRINT OR TYPE) g����' JLI Cer�ified topy is filed with fhe county build�ng inspec• A��ES'` ,� v . ' ����� lio�depa��meM. . . { NUMBER FIMURE OR ITEM � FEE �����, pole_1.�1—ApPlitont ` ` C r WATERQOSET NEAREST . . . CERTIFICATE OF,EXEMPTION FROM WORKERS' a4THTUe � Ca0555T. � COMPENSATION INSURANCE - ��R OwNER � . . . (Thl�sMton nNd not b�eompbt�d if th�work inrolv�d by ��� � . fh�pumH 1�!or on�hundr�d dollan(5100)or I�n.) IaVATORV qppqESS I cer�ify thot In�he perfcrmance of the wo�k for which this � . — . Permit is issupd,I shall no�employ ady penon in any manner � �NK � CITV � \ _ 5 . — so as io 6ecome subject�o�he Workers'Compenw�ion Laws. DiShiWASHER � � , � CONTRACTOR ; �qle ' erplicont � CLOTMES WASHER }ICE TO APVI.ICANT: If, after making this Certificare of ��� b d .tmpiion, yo� etiould become wbjed �o �he Workeri Sw�MM�niG POOI REffVioR Compersolion provis�ons of ih6 lobor CoeJe,you Inusl forih• �AWN SPRINKLER SVSiFM C'TY e � ��`.�� � wi�h tompiy wilh suth�provieions or this permit�sholl be STATE LIC. dEl1'n!d fevOklA. - ' WATER HEATER ������ � - � LIC�NSED CONTRAC70R5 DKLARATfON qSTRKi NO. PROCESSED BY I hereby offirm tlwt I om licemed under provisioris of Chopter D G�S SvSTEM - OUitEiS - �Ur _ �,o n� y (eommeneiep wi�h See�ion 7000)of Dirhion 3 of the Business _ puTlETSOVER . . 3 ard Wafeasiom Codv,ond my liceraa is in full force ard effetf. 5 PER SYSTEM FINAL /� VALIDATION �� (►��� DATE �` I/r� V Litense Number ��� Lic.Ciosa��L� � ` FlNAL 0 Controttor �S Uafe� BY W � a I om e.empt under$e[. � � a.av.c.ro.,n�:�e�o� Plan check fea Z -�137.2A I . ���Q� . PLUMBING PERMIT ISSUING FEE S �, . +*• d • • •S ( . Signature TOTAL PEE � + •�](�,5� Pton check oppllcanl e o e 7 6 5 p; . SINGLE FAMIIY . . \ HOME OWNER-BUR�ER OKLARATlON Nome �- ' � - �!7.�4..8 7- � heby affirm thai I am ezempt irom Ihe Conlractor's liceme � qddress �� � � - � � � � �- Low for the following reason(SeeNon 7031.5,Business and . � Professfons�ode): City Tel.No. � ❑ I,as owner of the property,.will do the work ond the atructuro is not in�ended or oHered for wle(Sec�ion -- - � � � - � - � � . � � � � � � - � 7(W,Business ond Profnsioro Code�. CONSTRUCTION IEN�ING AGENCY � � ' �� � � - I hereby offirm that rhere is a consnucfion lending ogency for Ihe perfpmonte of Ihe work fo�which this permit is issued - � � � � - � �Sec.3097,Civ.C.). . lender'a Nome Lender's Addreu � . . . . . � . I ce�r'rfy�har I have.eod rh�s eppl�coHon ond s�o�e fhot�he � . . . ► � � above infamalion is tarect.I agree�o tomply wilh oll Couoy ordinances and Slafe lows reguloling Plvmbinq,and hereby , , , , . , .. „ ou�horize representa�ives of this County�o enfx upon the . � obove•mentioned properly ior inspec�lon purposes. SEE REYERSE FOR E%PIANATORY IANGUAGE .�..F��l�oo g-3-81 Signolure of Permit ee � Da�e • ... - ' -- C � � S � Gl x' C N C D N C y Y D O _ - N tn G ,7 , . I . . ' � , .� rt v' _ ..^ { ~ �� j t � ;, A . . .� .... . .- , �. I `'T 'n "q T � v fn _ . I ' j i�' `� � C) #) � D � . I ' . �. i 1v ! �1 j� ` : ~•I £� � X " �: � � � \1 �j ?' �' 1 0 � `� {��:' � ,'' ii� : ; ?,' ` � �� r .( . I ,. . .7 � i ..4/ rJ--, � ��� " �.i; `,.u�j � "< < _ ,� r, � � � , �� `�, _ i. � , c:- . .�. �L'' \ , iT' �_� I .` � ,�,�� `�J � `_ �, � } N . Z ' ".. ' ' �= - J '_ �� ! \�' ��� ��'' . -Nn � .. �" �` �,,�,_ .�� . 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