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1374A (7)
_ WORKERS•connr�NSATioNoec�aennoN � - APPLICATION FOR PLUMBING PERMIT � 1 hereby,affirm iha�I hove a cerlificale of consent to self 70A887A insure,or a cattificote of Workeri Compensation Insurance, CE B77(REV.8l88) : � � � � orocer�if�edcopy�hereyo�i15ec. ,lob`�C.) � COUNIY OF �LOS ANGELES� � OEPTrflF•PUBLIC��WORKS � P�ol'�cy Na�`Compony .. . . . . . � .. . . CerYfied copy is hereby furnished. �^ �`� ' - � FOR ADMICANT TO Fltl W(pRINT OR TYPE) BUIIdNG SO V O '� � Certified copy is filed with the eoonty building inspec- ADDREu . li deporlmenl. NUMBER FIXiUREORIiEM � FEE �� �'j 'sehe(L�1 �ocAurv p1 Dote�tL((LApplitant WATER CIQSET NEAREST� . � CROSS ST. � Y�ph � ,CERTIFICATE OF ExfMPTION FROM WORKERS' BnTH iUs � � -��� COMaENSATION INSURANCE� py'��R . Ah � ' .. . .. , (Thi����clton e�ad eol b�compl�tad if Ihs work Inrolr�d 6y SFqWER � , . th�p�rmif is for om hundr�d dollan(3100)or,Int.) �qyqTpgy '��� AODRE55 I certify rhat in Ihe performonce of the wwk ior which ihis , . permir is issoed,I sha�l nor employ any penon in aay manner 9NK �CIN' ` n L _ 5Y , _ so as b become subject lo Ihe Wor4ers'Compenwlion Lows. - DISMWASHER � Q� CONTRACTOR � C� . Dnlr - ePPlimnt . . I� CLOiHES WASHFR - VV qOpRE55. . j -�iCE TO APPL�CANT: If, af�er making this Certifica�e o( ��� �� � ' fop+fon, yoo s�+ould become wbjec� +o_�he Workers' Sw�II,tMiMGVOOIaeCEPipa Compensotion provisions oi�he tabor Code,you must fo�th- - C�TY TEI. LAWN SVRINICLER SYSTfM wiih �omply with suth provisio�s or fhis permil sholl be STATE �IC. deemed revOked. � WATER HEATER ����� � � �SS IICENSED CONTRACTOR$DECLARATION � � DISTRItt NO. PROGESSED BY -I hereb�y affi�m that t om licenaed undar provisions of Chopter 9 GAS SYSTEM WTLEtS ' (commencing wi�h SecKon 7000)af Division 3 of M�e Business OUiIEiSOVER .. . . � Y and Professions Code,ord my liceroe is in fuli iorce ard effecf. 5 PER SYS7FM FINAI Q �— n,�� pA� � �/��- VALIDATION Ucenx Number��� � ltc.Class�--� V FINAL �y�,'f� � Con�.acior Oa�e�"� 3 F3' � BY /�I/�'���""'' U O W I om e■empt under Sec. �� J�4 A N .. . - B.BP.C.for ihis reason plan check fee - � _ , ,�. . . . .5 �1e� PLUMBING PERMIT ISSUING FEE j �'jp Siqna�u�e I � •7 6 5 Q TOTALfEE . . . . Plon chxk opplitant � s n ,7�S�u �. SINGIE FAMILY ��;1���8 7 \ HOME OWNER$UILDER�ECIARATION � Name - � _leby ofiirm Ihat I am exempt hom�he Comradar i License A���s _ . . Law{or rhe following remon(Seclion 7031.5,Bustnms and � Vrofessions Code): Ci�y Tsl.No. � � ❑ �,as owner of the p�oper�y,will do the work cnd ihe , struUure is no�tmended or offered for wle(Section 70dr,BuNness and Professions Gode). ' � CONSTRUCTION LENDtNG AGENCY ' �� � � �� � ' - I hereby affirm fhal there Is a conshuctlon lending agency ior � Ihe perfwrtwnce of Ihe wak for which this permit is issued . � � ' - - � � (Sec.3097,Civ.C.). . . Lender's Nome - � Lendei s Address � I cerrify�hot I hove reod�his opplicotton and s�ote rhot the - . ► above iafamorion is ca�ecf.I ogree lo comply with oll Coun�y ordinonces ond 51o1e lows regulaling Plumbing,and hereby _ . , . , _ _ _, au�horize represenla�ives of�his Coun�y to en�x upon the above•mentioned property for inspetlion purposes. � SEE REVERSE fOR EXPLANATORY LANGUAGE CQ .�F�r;�.it,c��-3-8� Signo��re of Oermitlee Date � �- • . , :=I y Gl .�- 'r G� G1 p C .. . . � � 3�U r.� � r y C C� Y 3` O 7 N� I y _ y , �n fn C rC�l � 1 i i.... ..�i ..� .� 1 � �, " ?' � 7 '? � T: , � i� _ ;.. ,r`. ;- I � "��✓� ( ;�:� II l,. - i� 1 G� c u a _. �.) ,►: � �I �,+J �I '�j c,': �� y; f� < 0 1. • � , ti: ; i 2'i t '! - 'i�; � ° r � � I � .���+ 1 �' 1 , �I` � (^ 'y .V l�' ��� N ' _ , . . - • . . it_ �`� �� �i� � �;� �� ,I � �ti- ;; �I'`��; I.��i'�, � �� ' ��j!; '' \:� �� i I. 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