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1001A (5)
� WORKERS'COMPENSATIONDECLARATION � �pp��CATION FOR PLUMBING PERMIT � VI Ke•eby,cffirm thoi 1 hnve a cartificale of consenl�o self 7gqB87A in Lre,�or a tarlificote of Workers'Compensalion Insuronce, CE 81T(REV.8/88) � � � � . � - or cartl0ed copy rhereof(Soc.3800,Lab.C.� � - � ' �3u�GoogpS3-voa3 COUNTY OF lOS ANGELES DEPT. OF PUBLIC WORKS P❑o�tyNo._�t Company J��rlaJfi�lD�3NUfNYJL Certified copy is hereby furnished. � FOR APPIICANT TO FILL IN(PRINT OR TVPE) 6UILDMG - � . : Ceriified copy is filed wi�h!he cou�ly buildinq inspec• �R� G .f�on depor�menf. NUMBER FI%TUREOR ITEM � FEE ��� I.%P�'' iocaurr - Da�e�Applicant WATERCLOSET NEAREST /. . . . CERTIfICAiE OF EXEMVTIO�OM WORKERS' BATH TUB . CROSS St. � COMVENSATION INSI�RANCE S��R OWntER (Thi���clion nNd not b�complN�d t1�h�work inrolwd by � tha p�rmiT is for ona hundred dollen(SI00)or I�ts�) �qyqTpqy D A��� D p�� . I cerlily thot in the performonte o(the work for which this . .p _ permit is issued,I shol�not emplpy ony penon in ony monner S�� ' CITY � ' y 7E�. �Hg� � � _ O so os fo become subjed to Ihe Wwkars'Compensption Lows. . 1 DISHWASHER J� U - 1 �// V CONTRACTOR C pota �6Pplitunt ' aoT�swns�rtv � ���. . NOTICE TO AVPLICANT: if, afrer moking �his Crtifiwie of p �, � Exemp�ion, you should 6ecome subjxt to the Workars' � - Sw�MM�niGPOpIRECEMOR ', Comoensalio�provisions of ihe Lo6or Code,you must iorfh- ��TY D� G/} n TE���' � . ilh comp�y with su[h provisions a Ihis permit shall be LAWtJSGRINKtERSYSTEM �A� �1 `� � deemed revoked.' � � - � ' WATER HFATER O ��CFNSF NO. J L�� QASS �i ' � LICENSED CONTRAC10R5 OKIARATION ' p�57R�CE NO, PROCESSED BY I V�ereby offirm tfqf I om IicaMed undr provisioln of Chopter 9 GAS SVSTEM WTlE75 � QO ` �(mmmen<ing wi�h SeNion 7000)o(Di�ision 3 of thv Business OUT1Ei50VER . V y and Professions Code,ard my licen�e�s in full Force�and effec�. 5 PEk SvSifM ' 0 (� �_I ��� tt 7� 'q/- PINAI. VALID TION p � � License Number �{��90fl lic.Class_.1�f� � - DATE V FINAL � O Conlra[lor Dale — BY _ . U � I om mpf under Sec. W 6. N B.BV. .for this reoson Plan check fee � � � _ ���. � � . VLUMBING PERMIT ISSUING FEE S � - Siqnolure TOiAL FEE �� �Q� � Plon theck applicanl SINGLE iAMILY j•'e • • n e j HOME OWNER$UILDER DECLARATION Name � � I hereby aff�rm�hat I am exemp�from Ihe Conhatlor'e lleense . � • 1 a Q$Q law for the following reason(Sec�ion 7031.5,Bu�iness and - Addroa. � •ofessions Code): City - .Tel.No. • ' � ����5 0� � � I,os owner of t�e property..wi�l do the work ond Ihe ��2(�..8'� s�rotlure is nof inMnded w offered ior wIe(Section � . 704�,Business ond Vrofens�ons Code). � CONSTRUCTION LFNDING AGENCY ' � - - � vffirm that there M a con�hvc�ion lend�op ogeney for - . mance o1 the wo.k for which thla permil is iesued - � � � � - - �- , � Civ.C.). .. • � ve read this applicanon oad sro�e�hat ihe � - ► . � is careU.I oq�ee�o comply wi�h all Counly . 'e iows reg�lo�inp Plombinp,ond hereby - , _ ��� �lives of rhis County to enrx upon the � � � �erry for inspecnon purposes. � SEE REVERSE fOR EXPLANATORY LANGUAGE' � ��y.8? . ..nee pote i ��- - . . . �=1 S C [) '� T O Cl U � . �,C f. = V1 } -1 (/� V� C U m y K � �. � ! v �1 '��` , . . I . : . �...� ;.T, �. n �, -• D. � y tn r . , I I ` - i ? � i =:r �',, '� O � �� G1 C � r � . . (. � n � - � i';. i ql i •�i U . � : i�r ~ O . i I � � I'.. I : _ I c � � , C) � � � ; i ' _ � 3=i: ,�, ' �� n �i A ' Fj � r . ; . I . , - i• I �- - _ f'li I. :+�I � ;IN I •. ± . 1-'�'1. .. ;= ;; ,i ►�; ; �i` ' ' . - .� '�' ;' . +-� ;"i; ij _'!:, ' u, n - � �� _ �I! i` I� \ jo , . , -� � . . %. ' " ; ' = � - �I l.' I� + fm " � � - '� .`I ;��,' - � ?_�' J F . : � �' : � � ^` ;j '�.. ; : . . .. , , ,. , . - 7 ; , ,•. :_ ,.•� � --,. I � ' - r' : _ ; _ O �—---- ----_ __... � i- -- ' T � I � '1 .� � ; ; • , i� :�. i '�" _ :;� ; rt, '- � •.f ! _ ` '!: ` . N il , i ;; .. 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