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1227A (6)
_ w•oa�Rs-foM��AT�o��E�,RaTro� APPLIEAT[QN F4R �L�IMBING PERMIT c� I � 1 hereby aiffirm-�thaf I twve a cerlifimte of consenf to se{f � Tgp667q - . � . .. . . - � ,' �� �osure,or o certificate of Workers'Eompensation Insuronce, �g�T��y,�p�grj _ � . . . . � � ��� or a certifi�d copy�hereof(5« 3B6Q tob.C:)- f,OURITY OF LOS ANGElES BW CWNG AND SAFETY �- � �,.r,o U t'�-F't$� �t 12�-�=� _, � �f��o���,��_,��m:� __ _. : � - � FQRAPPLICANTTOFIIIlN(PRINFORNPE) BUYIDING g" . �- -�Certif ied-topy is{iled wiih rhe-cau�ty buiEd'rrtg i�spec- - A6Ri�SS..�J� �aQl�j�jfG � �� �,iian dtaPm�men#. ' �_. . ..�.. ., - . NUM9ER ._-. FtxFUREi7RREM .___ � ..__ fEE r LOGUITY � .. . � �� ��-=�� � fry���� wArEq c�czsEr ___' {� �^+"—�3�—�--�—:_ . .__ __'___ ____ �-E9-___ ___ NEAR£5T � . ; CEf�FIFfCATE OF EXEMFTf4QN FRC3M WORK€RS'.. . .� �:I BAiH TU6 ._ '� r C�55 SF. � G C- -' . " � ���fOMPENSRFtON INSURANCE - � � - � �- { (ihir.socHo s na�aat IK coisptef.��-lk�work�Mvet vad:1+Y_. � sttavvER. . . . awP�k .r� - . _ - - - �iba pirnHt�lw iM IW�rr�daNars_(S��}�'I�ss.�., -.- . LAYAFORY � .hAA.IL . ` ..,_ _-___, _—_ _ . ADESRE55 _ 1 certify thcat in-ihe perfartnartce 6f-the-wark#or-4vhi.cA this - . . _ . c peimif is�ss:uedilshai4vrotemployonq�persort�in-prtyrr'cnner- w���' `�NK � � � `Z„ �- GF'Y � _ �;n�. - . saostct.become�:su�ieeti�s�tk,e-iYakexs'=€vm�nsati�s-lcyws:-- ---_- ------ ,._. _ . - _._.- ---- . ._ . . QISkWASHER - - Qate�'��—�•,••��.� .. . � �"! COlYFRAC70R � . . �,�o.,i ,f�t'III1�� ccQrHes wnsr�R —. _....- - �'-'�Cf�F6 APPLFCAhlT:If.'after maEing lh�s Gerti€icote frf� .. ARPRESS � � . . _ ' phon, you. shouid 6ecome w�leU to the-Work�rs` � SWIMMFN6Vp�RECEp7OR , .. ... '. .: .�- � . . �.-... .._�.,� , . . ... ... C��npeF+sate ort p�eetsons o�"the Labor Code you musr�Forth_..c_. . . . - �- {tt'Y"`_."•. •^'�-..n.:.•s^�.�`_�a,-<::: .-,...'[EF:=1�Y• ,.., ':.�.� ' , ,'. - tAWN SPRMKlER SYSFfM $TA.Tf with campi y svith such prows�ons ar this permie--shall be . �. daemed aevoked: yvar€e wEamt .r uCEr�SE r�. �(� cuss ;- .: l iCEN�D CONTRACTORSDECIRRATtQN-... � ..FNSF&KTttct: - . RR6cc5SEosv -- � t hereb-nffa�ren�shaa t am licens�d undaF ' pt - �s srs��u ��� �.. - . _ . � Y m .pravfuors af Gha_er 4.. . -.. ,r�^ .... . .. ;�. . (comrr�encirn�g with Sectroa-JQ�Q}af�Division-3 of tha 8usiness� OUtlEf50vEe . . ' y rsr�ns Fn..rA� „� AUDAFlON - �- � fh ,:-- license Nss��ons6�.cv��m.��LIc.�Cl4�aree���.�_° - SPER S.. . " �- '- '�--- _. .: ;..: V+4fE 4 f �i`r� ;.�' , � --", ':.: _ '`.a. 'l . -- - - - -` . �-g` -- co�,�,�,�, t�-f/,�Ju.�lf�/` _o�,e 7<�=�j� g�,u,� _ � ❑ _ _ u - F om exempf under$eC.- yy- a ;.�. ... ..B,&P.G_�feu th�s reason_. � - � .- . . . . vi . Flan check fee _ z i . -�_ Qatec- . - . : ._� � . � . . : .-� : � �� � - - PCUh16tM1lG PERMfT tSSUttVG F€E$ (� �. • s��,��- �t�2'7 A .. _ . �_ . _ . .� - � .-� � S4IA1 FE€. ��fl(� .�. . . . . . :.. _.. .. :.:. .. . _ . .. .:_. . . . .. . �`. s e-..i� _ . --'- ----- --- �- - � . . � . �__. _____._._.__._.._�._ _._ ___ . - Flon Cfieck appi�canf -- .. � . � � - SiNGtE PAMflY - . . . . - - - � �- . -�. HQME.OWNEft-6WLDER DECLARATION ._ . Name-- . _ .- , - _ _ -_ - - r. I� by aHi rm that 1 om exemp�from the�Gorttractor's€ecanse :. � .- ,. - - - ,-.- -- ,-_ , �_:.. .. - - 1 +�.��1.J�Cy _ . ' L ror the foilu+uiagsensnn jSectioct�763Y.S,Busiaessc.s�d.:`:_ Address . ., .., - - -- - . _ - -t.t.-�L'�A-�(�.�-' .-, .::-. ... - Profeasiar�s�s�de):--� . - . - � . . - � Cily.. - .. Tel.Na � - - - �7 li g"'El 3�� . ❑: t,as owner of.the p�nperty,wilt do the work ancf the - �- - - � _ � � � _ � - - � . � - � � - ', �,�- � � struck..rre'rs not inteoded or offered fer wfe.(S.ecrion - � - ._ . .. . . . _� . � . - - �.. 7044,- Business ond Professions Code). � , . . � � - - _ . . . � . . ��. � . . � �CONSFRUCTION lENOMG AGENCY � . .. . .. . . .. . . . � -. . . � - � - '. fherebyt�ffe�m-thaitheraiaa.construciian-fend�n9a9er��1`far._. _ . .__ . _ . _.- _.-. . -. _.. . .__ _._ _ . .. . _.. ��.. � � rhe-per#arma+�e-eftk�wak#o�wMzN-aFtisper7nis=is:ssued-._ . - . - . I E' (Sec.3047,Civ:.C�. _�. - . -_ �-- ---- . �-- . . . , "- tender-sName .. ._. - .. . . . � . . - _ .. . . . ._ ... .. - . . f ,.. .-�: ..-- --._. ___�.__ _.__..-- __.. _ . . . . �- -; tBnder'sAddre��- .__._ .. _. .�_ - . . . . .� . . - . . . . � . ..� - - I ; 1 cerFify t6o:i.d hoxe read tkis appkicsfion and-stote fhaK�lke-.. ..� � . . . ... -- . � . . � � - � . i aboveinfen�nufiantrctureeF,4�sx�c�etat�complywith<sk4Eoumy � . . - - . � . ; '- ordinonces cs�d Stote�aws-raqu�at4ng-Ptumbing,�ar�d taereby - - . - � . . .. , � . � - authorize represeninttvt5�trf this Counry to-.enfer��upon the - . � � . . � � � � - � - - � above-m ntio�ed.property.4or inapec{ion porposes... SEE REVERSE FE}R EXPLANRTORY L{fNGUAGE � � -,.. �Si nn o£Rerminee_.... ._. Date ... . . . . .. � . � � . ... _... . ....__ .. . . . - ._� .- � - � � . � _ . . . . . - .. � . � ' u� L W-C� H C .' 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