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"'°RKERS•�°""E"5"T'°"°E��"R"T'°" APPLICATION FOR PLUMBING PERMIT {� �
I here6y offi�m Ihal I have o certi(imte oi consent lo seH - �yq�y�q LI
insure,or o certi{im�e of Workers'Campensotion Insuronce, f CE 8V(REV.IOi81) . . . . . i
or o�ce�rt�fi�rpy��3800,tob.c. COUNTY OF LOS ANGELES I BUILDING AND SAFETY
POolicyr7o'. Compony '
Cerlitied copy is hereby furnished.
� FOR APPLICANT TO FllL IN(PRINT OR TVPE) BUIL�ING (�! M�J
��enihed copy is filed with�he counry building inspeo- A�DRE55 l !
� p����� NUMBER FIXTUREORITEM (d FEE ����T� '
WATER CLOSET v
Da� Appli4a�� NEAREST / �,� �
CERTIFICATE OF EXEMPTION FROM WORKE S' BATH TUe CRO55 ST. �._,(iyV► ����t��'✓��� �
COMPENSATION INSURANCE OWNER ���-' �
(Thi��edien n��d no1 b�compl�l�d if Ih�work(nvolvsd by SHOWER
MAI� � /Z � 1
Ih�pe�mlt If for one hundnd dollars(3100)er Iqa.) lnvnTORY
ADDRE55 ���
I certify thot in Ihe performonce of the work for whith ihis
-permit is(ssued,I sholl nm employ any pe�aon in any manner SINK CITV �'v��� - TEt.NO.���
so as to 6ecome su6jec�to rhe Workeri Compencn�iOn laws. DISHWASHER . ' �� ��
- � CONTRACTOR
' pote Applican( CIOTHES WASHER AWRESS �`
NOTICE TO APPLiCANT; If, ailer mokinq ihis Certificole of SWIMMiNG POOL RECEPrOR
Exemp�ion, you should become subject to the Workars' � �
Compansmion pravisions of the Lobor Code,you muat lorlh- UWN SPRINKLER SYSTEM GN �, TEL. .6,�' (
wi�h comply with such provisions or this permit sholl be STnTE / �— LiC. /'� .
deemed revoked. . WATER HFATER ���N����'!��i�� CLA54✓��
. IICENSED CONTRACTORS DECIARATION. . DiSTRtCT h�0. P ESSE�ev
J here6y oHirm thal I om Itcensed under provisions of Chopter 9 - GAS SYSTEM � OUTLETS `
(commencing wi�h Section 7000)oi Division 3 of the Busines5 . OUitEi50vER
ond Pro(essions Code,and my license is in full force and eHect. 5 ffR Sv57enn FINAI � VALID I�N
����+ � DATE 8 �
License Number�l� "�/_ Lic.Gas�� ���y� - O
�l��L��'1%�� 'y / BY AL , U.
Conrrocto a � �
�
❑ O
I om exempt under Set.
8.8P.C.for this reason ► LLVj
- - Plan check fee p.
Do�e: p��MBING PERMIT ISSUING FEE S �� ']7,p� Z
Signoture
TOTAL FEE $�• • • •5 .
. . . . . ' � . Plan check applicant � � • • � Ey 5�
$INGLE FAMILY
HOME OWNER-BUIIDER DECIARATION Name � � � � � � �ri��
I hereby affirm thol l am exempt from the Conhacror's license qddress �
Low�or ihe following reason(Settion 7031.5, Business ond ' � ��.p 8—8']
Professions Code): City Tel.No.
❑ I,as owner of the property,will do�he work and�he �
sfructure is not intended or oFFered for sale($etrion , - �
7044,8usiness and Professions Code). � � ���� ' --� � -� ��
CONSTRUCTION LENDING AGENCY . .. . . �
I hereby nffirm thot there is a constrvdion lend�ng agency for
the performance of ihe work for wbich�his permit is issued . . . �
(Sec.3097.Civ.C.). ' . . . .
i
Lender'e Name . . . .. . . . - . � . . . . .
lender's Address �� �� � �� � �
I ce��ify thot I hove read ihis opplica�ion and stote�hat fhe �_
above informotion is correct.I agree ro comply with all Goun�y � ' - � � �
ordlnances and S�ate lows regvlot�ng Plumb�ng,ond hereby .
au�horire rnpresenfoti�es of�h�s Co�niy�o emer upon fhr � � � , . .
obove-menrio�ed property for ir+spection purposes. SEE REVERSE FOR EXPIANATORY IANGUAGE
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