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1214A (6)
, 4e+ . f - - �M'ORKERS'COMPENSATION DECLARATtON - �pp(,1eATIQN FOR PLUMB[NG PERMIT � � - � , !hereby affirm�hat I have a certiticate ot tonsent to salf : 76q66�q . .. - . - insure,outa cerii&cate of Wwkars'Compensation InsWonce, � CE BV{REY.l6i81)� - � - � - � - _ «a ce.r�fle�d mpy rhereof(Ser. 6.C.) C�l1NTY OF LOS AMCsELES 6UILDING AND SAPETY � 3� ' r C . Poticy No. � Compony . . .. . . . _ . . - _� _. ._ . . . _ _ . �-�Certi#ied copyr'ts hereby furnishec#. ��. -- - --- . roR nr�tcnwt To�=�u rN�vRu�oR rra€� eunoinic �I OCt 1� �. ' �ertrf�lad copy is iited-witkthe�tourtty-bu'rk}irtg impec- - . . AQDRESS . -NUMHER ... FIXN2EORF7€M � L9CAtMY-� . . � ..ti6n tYepartrtteM. .. � .. � FEE . . . . . DaFe+��'��a✓ Apptitant � � WATER QOSEf . . r NEARE5F � G/_ f C. .. .. ''., CEf�FtF7CATE OF E%EMPff�N FR6M WdRKERS` - �j� BATH FUB � - �� �,�. ��`�ST' - �J I tL (� I . . . COM�fPiSATJON-{NSItRAt�E-. -� � �. � . .. . . (ThfflKtFOa�nfaolf�mmplekad�ihi.arorltiavoFwdby.. - SHOWER . . .. . .. QWNER . . ,�ut e� � .F Hw pQrm[t !�fa�mw huadra�doilars filA4}sr7eas.� - tavarorzv - � . . � '�' MqoDReSs �� t� . � � r � . !certi#y fkat-iw-the perhrrma�e d ihe�work#er-whieF Ihis.. . ...- . -. .. peemt!�s iss:uad;Ysfialtriof emptoy any persofl in any monner Z_ SkNK � . ,�.� �ETy �� !��t . TEL.Np - - so ai to become subject ta the Workers'Compensation Lows. � .. _ . � � � � -.! � - /'-Y.�tiS� - . . - QISHWASMER . - +" CONTRACTOR . _. Dote n.,.,_�Iicant �'': . : C CIOiHfSV�ASHER-. . ••—� n�oRE55. �' . 6`""-'CE TO AP$IIGANT: tf,--after mttking th4s Certifi<ote of��: .. SWIKJeSB�K"aRpERECEFfQR � . . " � ..become sub{ect to.the-._Workers' � .- . - ' ;_, �:.:._. ,.^: R: .._:._;. �tfhpcampi y pth h uch ofi the lab6r�Code,You musf€anR _.-- .. :_ ._ ._ . --`�- CRY.. -_.-.. .� -�:���- ,-�.. -'�€t"Nb...' P Y . Cv�n enscvti on rovisfpn5 ' . provisions ctr this permit,hafl be �0.WNSPRINKtERSYSTEM STATE - deen,ed.e�..oked. t waha�nhR ,... uc�Nse nio. � ��� ��� �.. L.IGENSE6 CONFRACiQRS QECIARRTION DIs7Rl[[NO... - - PRd�sSFo flY - 1 k�reby offi tm ihat f om licensed Underprwrs�ons o#Chapker 4 � . �SYSiEM �� E7UTI.EiS�-. .*-- � - /,r . - : � ( � (commenang with SeUmn 7EqOj of D'rvision 3 of th¢Bus"rness {x��E�spy� lfJ � .. . -..� - and Pr4fasrvns Code.nnd my I4cense ts[rs fufl fprce and e4fecr. .� 5 PER SYSTEM . . - Y �� [ ntwanoa� c► License Nu ber�� �' � tic�Class � . . . ..�. . . ... ... .-. _ . .�.��� . . �- V j . t��` - fiN11 � . . . . . . a i : ConNncro� �—�nare ��"'$+� . _. _ . . . gY � - � - � - 4 _� ❑ ._F�nm�xempt under�ec. �- . � . . . . . . .. . - . - . . _ . . �_ � . . _ . _ , _ . . . . _ . . . _ _ . a , N: ! - B.BP.�.for th'rs reason Pla�c}leck fee . � -. .� �. . �. .. . - 2 `: - Date: . . � � PLUNV6ING PERMlT ISSUPNG FEE�$ �:�� . - - i _ Signa�ure� . . . . . .. . . �- � . _ . ._ . . . � . . . . .. . . . TQTAL FEE �. 'QQ� - ._.. . . . �. F I ��I.Li A ,. � i ' � , . _ � . � ...-. . . Plan check applicant .. . . .. � �}s � e •-..V - ' . _ SINGLE FAMICY. . . � HOME OWNER-BULLbER flECLARAIION ... . Ptame . . . I • � O�G�} _:.I 1 6y affirm that 1 om exempi€rom tFie Contractor's License A��$. -- �L� .w th� fttillowiag.�reusw>(Secti:us�7�:}7,5,&�s4iae55 emd � - - _. . ���- - ' - �- - -+�-+�i�i v v��i u �. � _ .-'`_. r ._.�.,�;, ,__ .:..� Prafessions{ode�: � � � � eity � Tet.hto, - , ❑ 1,as mwneraf the praparty,will do the work and_the � - . � . . � - � . . Q 7 C��R� � . �, . �struciure is not intended or affered for sale (Sedian � - - - . .. � � �- - � - � _ .� �_ � � . . .�64d, Business ond Professions Code). � .. . - . . . � . . . - � C(3NSTRUCTION LENDfNG AGENCY � . - �� � � . - � - � � � � � , - I here6y affurm tfiaf fhere es a construdion tendir�g pgency for . ; - - - - . . � . �� � � � � � - .. � the.performianee of�he work for which rhis permit is issued��. � . -. . . �- . � . - � - � . . (Sec.3047.�Civ:�C.}. - � � . -.. � � . . . . . . . � lender's Naime � .- � � .. �� � .� Y . � � . .- .� � . � � � � . tender's Ad�dress � . .. � � �. . . - � . � � -.. � � .. � .. -� �I certify thuf I have read-khis applitatian and state fhat the . � . . � � . � - . � .. � � - - � above infarnaaion is correct.1 agree to comply with aR County . - - . . - � �- ordinantes ond State lows reguloti�g Plombiag,at+d hereby � � - � - � � � � - � �' authorize�r�presentotives.of this County to enter upon ihe � . -- - - - �- � � . above-menitioned prope r irtspedion parposes. - -- � - - - � - . - � � � . . �- � � ���� SEE REVERSE fOR EXPtANATpRY LANGUAGE � 1 � Si a re o$Permikee � 6ate .. . . . ... . . �� � . - . . . .. � 'vk` � � � s o o�'�o � � � � � � °' y � -9 G ��„ 4 N N G t', . - .. � . . . . o `� �a � 01'z.., �' '�' � a.`� D 6 $�� j��,.-. , . � �. � t,C al �L '��p VN p �. .O � �f`�� C' N [-, �p _ . o� s Q N m o rn& �,� .� m n 4?,�t-- d°.c �'= °v o '" ., Ti Q 3 ��� c v�O-o� v� �b-., =� � c ; � �o fl.� . � � D�T=, fs- G = O C p G �� 'O `5"bp p'O � 70/ � v'�"'" ' � ' i 'D p�w � O p 0�.C �-p � C P- O � O - O O p !� C N O � 4i E 6�s r"�„O � Ey p�T� �...~�. . .. v � � 0 5 m a$ «� ° . d '� m a° o�s-c a °' e" �. n O � y a r m O•j . �„ .j,,,- .T m '�.� p Sy 61 ij-r. . . 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