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1317A (7)
• WORKERS'COMPENSATION DECIARATION APPLICATION FOR PLUMBI G PERM_I� 4� ,I hereby,offlrm Ihol I hove a certiffcoM o{consent�o self 78AB87A . M l ' � insure,or a cerlificote of Workers'Compenwtion Inwronce, CE 817(REV.8/86) . - � sO `1 �1�, � .-� �'" � . or a teriil�ed copy fhereof�S e 3800, b.C.)� . . . � � 1 3 -tl� ��a COUNTY OF LOS ANGELES DEPT.- �PUBLIC�WO�tKS P❑olicy No company . . . . . . .. � .�i.. :� �� . . Ceriified copy is hereby furnished. - � FOR AVFLICANT TO FllL W(PRINT OR TYPE) BUILDING �� t.'��� Cerrf�ed copy is filed wi�h!he co�nty buildi�g inapec- A��� lion depor menl. NUMBER FIXTURE OR ITEM � FEE �rJe�'f �c� IOCAII �,�� pple � Applitont r WATERCLOSET C./" NEAREST . CERTIfICATE OF EXEMPTION FROM WORKERS' p` BATH TU9 � «O55 Si. � .COMPENSATION INSURANCE OWNER � �• (Thi����cllon nNd nol b�compl�l�d IF fM work inrelv�d by �wER � , - 1�• �rmH ls for on�hvndr�d dollan {I00 or I�ss. AhAit . . . P � J I � LAVATORY q��� I cerlify fhat in�he pedormence o/Ihe work for which this , � . - permil is issuad,I shall not employ ony person in any monner ' �NK � pTY D V� ^ , TFL.NO• � - 5' _ w as�o become subject�o the Workers'Compemalion Laws. _ I DISHWASHER � Qp � . . . . CONIRACTOR � l�C�� I Dote ' �pplicont - CLOTMES WASFIER (� a(`� •. � � �ICE TO APPLICANT: If, afler.making�his Certifimie of A�E� � � � � � mption, yov should become subjeU to 1he Workeri - SWIMMING PppL RECEPTOR � � CemFMnso�ien prnvlsions oi fhe lnFpr C�e.Yoo mo+l fn.�h. CITV (�� TEI.NO.b�� tAWN SPRItJK1ER SYSTEM �Y with compiy wi�h s�th�provisions or �his permit shoil be STATE �1 �^ ��� � dEempdre�Oked. � � - - WATERHEATER UiD L�CENSENO. �W . - LI�NSEp CONTRACTORS DKIARATION DISTRICT NO. PROCESSED eY GAS SYSTFM � OUTLETS I here6y offirm thot I am licensed urde�provis�orn of Chop�e�9 .� � � - (commencing wi�h Setson 700Q)of Div�sioa 3 of rhe Businesa q�T�EiSpyER a � ' and Professions Code,and my license is i�full force and effxt. 5 PER SVSTFM FINAL /R`/�� VA��pa��N V: license Number-=�Z13�lic.Closs�Y.L DAiE � a FINAL O Contracror '� Da�e9-��2 BY � � V , �❑ I am e■emp�under Sec. - � � � 6W. W 8.8P.C.(or thie reasan � � 2 Plan check fee Dote: �� J�.7 4 . . PLUMBING PERMIT ISSUING FEE E � . Signature :: a • • • •J . � TOTAL FEF " � .. - .. . - Pian check applicont � ' -°�L J i� SINCaLE FAMILY p a £-�J��r � l HOME OWNER-BUILDER DECLARATION Name lFeby offirm tFwt I om exsmpt from the Conhoctu'c Litence Addreas � � '�i.�c�'.`-u�i Low for Ihe following�eason(Sec�ion 7031.5,Busineas ond Professions Code): City � . iel.No. � ❑ I,os ownei of the property,wiil do the work ond�he str�duro it nol in�ended w oRered for sale (Section . . � . . . 7pAd,Business ond Professions CodeJ. � � CONSTRUCTION LENDING AGENCY � �� � � � '-� � - � - - � - I hnaby offirm�hm there i�a comkuuion lendinq agency for � � - rhe performance oi the work for which this permit is issoed �-� � � � �� � (Sec.3D97,Civ.C.). Lender's Nome � � � lende�i Addross . � I certify that I hove road this applimtion and state that the . . . ► _ . _ . above infwmation is corract.I ogree ro comply wi�h all Counry � ord�nances ond State lows�eguloting Piumb�ng,and hereby . _ _ , . . ' outhorize represemmives of�his County ro en�er upon rhe � � �� obove-mentioned properry for inspection p�rposes. • ,/) ,� �� _ „^ ���J�� SEE REVERSE FOR EXPLANATORY tANGUAGE ��,� �// Signoture of Permittee Y Date . — . , . . . . � ..�7 C � T 2 Cl Cl 70 � • ... y�c� y _ N C O in �n � Z ��^ K T ca < < � G1 U . .. � �-- - - .,�i� ' - n cy � i�• � I z r^ D I � ; '��.,; ;?' — � 4' Y c� E m i i j �;;� ' �; I �; � _ � c� � `�. '� : �S I , ' :- i., � :=; _ � .:_ I ;_ i; � ~- • .. . � � x, I ' T. �, �' ! "t ,r-:. `1J I f /}''� I ,,,� f`,--*.��'. � .1 ( . �C7 ... i; '` �.. i y_ i/ li `� �.l 4:���`.'��: ' I 1�1 - �\ ' Y ,' _� C � _ ' v\� ' _ � � '�l � ; _.�~��^' O � !... , � � � � � ,I I .�. � ' I . � ' � � �! � I ` � �y. 'I�� • . o -- -- ---- 1.-- - '��'_- ��:�1 � �. 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