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0497A (4)
�WORKERS'COMPENSATIONDECIARATION qpp��CATION FOR PLUMBING PER�I�� � n � I hereby,aifirm thoi 1 hova a cartificate o1 consent fo self 76A867A . .. . . � . "�I insure,or a terlificoir.of Workeri Compensolion Insuronce, CE 817(REV.8/88) - - � � . ., u . . � o❑r n Yerti�d co � (�Y80o,lo '�>� COUNTY OF LOS ANGELES DEPT..OF PUBLIC ORKS Polic N C n �r�� , _' �':• . r�ified copy is hereby furnished. BUIIOMG /�-y1 Certified copy is filad with c nl b�il e i �. FOR APM�CANT TO FIIL IN(PRINT OR TYPE) ADDRFSS . U N�W OV�l/ tion�porlme�� NUMBER FIXTUREORITEM �j FEE � � %f— J(J M� �oc�u'TM �'JON/' Dote__���"�}YApplitan �' WATFRQOSET � W NEAREST y1� �,,1 �,�.�/.J � . .CERTIFICATE OF EXEMPTION FROM WORKERS' Bniri iUB � . GRQ55 S �•T�� /�YJ (/� COMPENSATION INSURANCE S��R ' OWNEA � '' � � (Thi���dion nNd no1 b�compl�f�d if Ih�work Inrelr�d by ��� O � tA�p�rmlt fa lar on�hundr�d dollan(SI00)or 1l�s.) UVaTORY qpp - I cerfify�hol in the pe�iormanca of rhe work io.which�his 'r ' ` _ permit is issued,I sholl not employ ony penon in any monner SINK CI7V _ u J so os to bacome subje��io rhe Workers'Compensation laws. DiSHWASHER .p f/y U _ � CONTRACTOR �JC.i � ��:�e eppliCant , CLOTHESWASHER y� �E� � � . , ,.=}�I�OTICE TO APPLICANT: If, after moking this CMfifimte of SWIMMINGPDOLRECEPiOR , E.emption, yoo should become su6jecl to the Workers' Comoensotion provisions of ihe Lahor Cod�,you must forth• CITY �h, with tom 1 wilh such rovisions or this rmil sholl be �WtJSGRiNKtERSYSTFM PY� P P� �� STAIE LIC. r deemed rovoked. � � - ' WATER HEATER d� IICEN$E NO � ��/�5,5 - ��UCENSED CONTRACTORS DECLARATION DSTRiCT NO, ptOGESSED BY . �I hereby offirm lhat 1 am licensed onder provisions of Chapbr 9 GAS sv57EM OUt�E75 6 0 �� f]�a`b{�2 (commencing wi�h$ec��on 700pJ of Division 3 of the Business OUiLEiSOVER . ��� y and Professions Code,ond m li r»e is in fu�t face and eK 5 aeri SvSiEM � a �'��� �r FINA� VALtDATION v . license Number Lic.Class � p� DAiF �^Z.11�g� FINAL � O Conhocio� � r BY � ❑ 1 am exempt unde�Sec. W a B.BP.C.for this reason Plan check fee . �- - , z Da�e: PLUMBING PERMIT ISSUING FEE 5 Signature iOTALFEE . . . . . .. . Plon thetk opplicont ' . � SINGLE FAMIIY . '�0 4 9.7 - HOME OWNER-BUILDER DECLARATION Name . #._ �(� . '1 hereby oHirm tho�I om exampf from tha Con�roctor's License ' � � Low for�he fol�owing reoton(Settion 7031.5,Bufinesa and Addross- - I • � O b 5� Profassions Code): � City Tel.No. ❑ I,os owner of the property,will do Ihe work ond the � ° • � ���J�� structu�e is nof intended or oRered for�ole(SeUion � � , 0�O 6`$,7 7044,Bueineu and Professions Code). CONSiRUCT10N LENDiNG AGENCY � -� � I hereby offirm�hat rY�ere is a tonsh�ciion lending ogency for fhe performance of the wo�k for which this permi�ia issued � � � � � � � (Set.3097,Civ.C.). - - Lender a Nome � lender':Addross � I cerfi(y rhot I have rood this applimtion ond s�ate�hm�he � - . . . . ► . obov (wmolion is correcl.I agrce to tomply wilh oll Counly � ordi on s ond S�afe laws regoloting Plambing,and hereby . aufh riz represen�a�iv oi thia County to nter pon�he � � � - - � � � ' - � � abo .o ly 1or inspeclion p oses • 'Q� SEE REVERSE FOR EXPLANATORY LANGUAGE �J notvro of Perminee ate ! i �` . _ , _'. ,... �, . . . � ' ' � c � � T C� C� z� c D c T - �; � � v� cZi� C� c� ' N�' rD- r �-`,'� ! ! T � N � r I . i ;.'�i`:' ' a;i. " i r- ,c�i `� ii n �� i �: � : -- l JI .. , � � . I i.�J. i l,l� C.. ,�I', V y x � f3 � O ,. I , � (,' .-,'•�.� � ,I. =' c �� `. %� �> r � . 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