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0819A (4)
•�T -. - WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT � , I hereby,olfirm Ihot I hove a cerli(itate of consenl to self 78A867A • inwre,or a cerlifico�e ol Workers'Compensalion Insuronce, CE 817(REV.8/68) � . � . . � . .. - � . o.o ceri�fied copy thereot(Sec.�800,1a6.C.) COUNTY OF LOS ANGELES�_.�.., . DEPT. OF PUSLIC WORKS P�olicy No. Company - . . . . �. '..J� •.•.•.: • , . � .. . , . Cer�ified copy is hereby furnished. - �^ ' FOR APf11CANT TO Fitl IN(PRINT OR iYPE) BUILDING �/y� Certified copy is filed wilh!he county huilding inspec- �`� ���� � � � T tian department. MBER FIMUREOR ITEM � FEE � .���j 7 - LOULIiV � {/r � - - . Do�e�L�.AOViiGant WATERCLOSET ���T , , , . CERTIFICATE Of ExEMPTION FRO ORKERS' BnTH 7U8 . CRO55 ST. � //-a�i1.� COMPENSATION WSUR NCE pyy�R � /'�- - _ �.�:�t';. .. (Thi�uNlon nnd not b�complN�d if fh�work involv�d by SNOwER '.'�,- � . ... . th� �rmH is For vn�hundr�d dollon SI00 or I�sf. '�'�� � . P I ) I L4VATORY qpp�� �„r,�.�J - I.cerrfy�har in+he parformaoce of the work for which rhis 7�y , _ — permit is iuued,1 sholl nm employ ony perwn in any monner SINK dTV . TEL NO -- so os to become subject�o�he Workers'COTpenSoliOn LawS. - DISHWASHER �� � . . COMRAttOG.� .� t!/ j,� . . . .. . potc . srplicant - CLOTHESWP.SHER � . NOTICE TO APPLICANT: If, after making Ihis Certificate of A�E� - /f�� �Ld � /Q/CI - Eaemption,..you shoold becoma subject fo �he Workers' SWIMMINGPOOLRECFPTOR o . Compensalion provisions of Ihe Lo6or Code,you mvst forfh- � ��ry �.d�//i�.t G ��'�' _ "/ wilh comply with su[h provisions w this permit sholl be �AWNSPRINKIERSYSTEM . STATE LIC, deemed revoked. - � - �� WATER HEATER ���N��� �� � ClASS LICENSED CONTRARORS DKUIRATION � dSTRKT NO. PROCFSSED BY � � I hereby affirm Iho1 I om'licensed unda provisions of Chap�er 9 GAS SYSIEM OUTIETS 2 (commentirq wi�k Settion 7D00)of Oivision 3 of ihe Business OUTlETSOVER _. � !� and Profeuions Code,and my licente is in i�ll face ond affect. 5 PER SrSiEM ' d � y �� a/d / O FINAL � Z� �� VALIDATION � Litanse Number � ll 1 Lic.Class� L DATE � y�i FINAI 0 � Contract.a�u . .` ate �'.1 y—�7 pdL � � BY . � � W I om e.emp��nder Sec. ` '_ � , . B.BP.C.for rhis reason Pla�check fea . - � z Dota: O "Q r;�,�rZ MUMBING PERMIT ISSUING FEE S Signoture F . e . . .� TOtAI FEE Plan chec4 applitant � a •��j:� SINGIE FAMILY HOME OWNER•BUILDER DECIARA!ION Nome � � ... . , s?4 ^��= I hereby aHi�m tha�I om exempt from rhe Conrroc�oi s licerne � � � • � Low for rhe following reason(Section 7031.5,Bosineu ond �dress � � � � ���j=j_i�'��� Professions Code): Ci�y. Tel.No. ❑ 1,os owner oF the praperty,will do the work and the � j,�l� U aI� �a atr�tture ia not iMended or offe�ed for wle (SecHon . ��i Q Q T� Q - . . . . . . . 70e4,B�sinees ond Professions Code). • CONSTRUCTION IENDING AGENCY ��i�/'�Gf �~� 4F � `'F' I hreb y offirm�ha�iherc ia a conpructio�lendin q o qen c y for O���nC 1��"C �p'/��<*�„""L the perfwmonce of the wor4 for whtcb�hts permit is iss�ed � "��7 � - (Sec.3097,Civ.C.). � lendx'e Nome � Lendsr's Addross � I cerrily that I have read this applicotion and state ihot the _ . . _ ► � ._ � abo�e infamation is carect.I agree to comply wi�h oll Couny ord�nonces ond S�a�e lowa.eqolor�ng Flumbing,ond he.eby � - authorize represenrotives o1 this County to enter upon the � � . � � � � obova- Nione perty for Inspec�ton purposes. SEE REVERSE FOR EXPIANATORY UNGUAGE ��`Z.7� . ignoj o Permine Do�e � i l � .. . . ... .. . . . •=7 „ C G� T' S Cl Cl � C N L y � r -�-� N Iri� C C'J m N � --� ' f � _J G� � . r � 2 . . 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