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1215A
_ _._ __ _/ _ _ __ -- _ _ _ �• - - W�RKERS'CQMPENSAf16N�ECLARATI�N � � Ly�P"��CAT�ON �aR P�V��'�V �GR�YI'1 � - � t hereFzy offfirm tFwt I�hpve a certificete ot,consent to seff �fbq��q . . . . - � insure,or a-cerFi€icate o€Wwkers'Campansafiort tnwrance. LE 817(REV.10/81 j - . . �.. . � . . . or a cerr�fied copy thereof(Sec. i o6.C.) CQUNTY 4F LdS ANGELES BUILDtMG AND SAPETY �j 4� �«y wo. c���y �n�G P_a,r �7 - -Certified copy is hereby fornished. - - � -- �t�� �- � � FOR itPPtiCJtM TO Fi[l tIJ(FRINF QFF TYPEj .. �[Q.e'r_ �B � . .. � �Gerti4ied topy is£ited-with!he county buifding inspsr ADDRESS •�r Z- - F�an d� rtme�t. - . - -- NUMBER -� - . PIXTUfff OR tfEM � � � � - Q { t�nun 6ata .� 1 qPRli4ant . . . . J WATE&CIQ�T .. 4 .. .. � NEAREST �. . . � � � � . . � �CERA'IFICATE 6F E7EEMPTION FRt7M WORKERS' . ' . .Zy`- BAM Tus- � � - .R +�� CRO55 Si.-S - Lf e1�,I`� � �. � - . - �. . ...COMPFhfSAFfQNiNSU&hNCE. .-.. . - � OWNER � - . . . . (TlN�svc#toe�ne�d mrt bt euinplWwf#-tht work�bLvolwd bp SHOW€R . . . . . � . tho pQrmH ia►or one hundnd dolfars(St�J}or bss.} - - � �+�� � ' -� ' tavAroar � , aornteu 'f ctt� (�!� .. 1 certkfy that in the performanca of the work fw wRich tfiis �y � � � . �f . '; - permit ia issired,�4�shalk+wt empfo�.anp-persop�ertcrtiy manner. - �,�+. SINK .. . .. .. . . � �i�'�� C� � � �� . . FEL.t�. � � . so as fo bec�ne su6ject to the Workers'-Compensation Laws. { pE5HWA5t#R � � . � - � � � � � � � i ,�J L�`(` \ '! CONTRACTOR 5�.� �sr - pcte�"��J...A�Flican�i:.t C1F'e�. . CLOTkES WASHER -� �- � - . . . . _ . . M"-'CE TO w4PPLICANT {f, af4e€ mok�ng th�s Cxtrf�mte of ADORE55 . ..: _ __ _,< -,.. :<_ _.,.. pt�on, .yov-:_-choet7d kaetome.ssrk�Eee4 tQ the:SMor�ca�s' :.-_ SY+C4MMING�.REC�PiCSft.. --_ - - _:- -_, � ��n +ssa4ic.r+ ovis�ons o#`s7�e La�or Code , . --- - -et� �- —""�-.' „�`_.- �.�_� . -_ -_.� ae ar v9++�n�s�io�rX iawu saaiw��Q svsr� e w�th�comply- wiFh aucFr prov�s�orts er-this permrt thalt be � - STATE n � Jj � � G/ �� i � deemed rcvoked: � . � WATER HEATER - -i LIC€NSE Np. f�q� . . . � -IICENSED CONTRACTORS DECLARAtIQN� � .. -�i���._ . ����v. . _ . .. 6 hereby affirvn rtxit E acrt.I�cartsed.under.pravis�ons.of Ckapter 4. �..... GaS5v56EAa �..: OltTCEtS - � "'-�' - - �- . .. - - �� . , (c�nmeocing with Section 700Q)af Division 3 of the Business p�7�py�R � � . - - � � anct Prafessio,ns Cade,arrd my.Rcerue-is in£ult fwce asui e#€ect.-- � 5 PEs SYS7Ean . - � - - . . Y �»�� z Y fdATFON g - Ltcense-Nu//��m.�,�,b�er Eic.Class - `� '`-� . � y ,. .:.. [_/ t � ��.� .': .ifti. � -Q � . - . . FINA! ;.,t _ � � . . �� � � Cantradof. F� �«-�s Lnte /� �u� _ 6Y ^- .. � . ❑ . -- - . .. . . . . _ � . � . � . . . . _ . . . . -. .� � �am exempt vnder Sec. -g .. � B.&P.C..for ttiis reasan �� � � - K+ � P(an check fee Z � �a�e: - � �- � f'I.UMBING PERMtT ISSUING FEE� t� - . � .�. - . - SigYlptW�C _ - - . _ �- .. . . . . _ � TfSTAL fEE -�_:�EiC� Q . . � ..._ z� ��.�N -� . ... - .. . . - . - Plan check.oPPlicaN. . .. .. . - . . . . _ . - $e�i i t �5 .-�-.� - . . . SINGLE FAMtLK . . ... . . . - - - . - - . . . � HOWtE_OWNER-BUIF6ER DECLARATfON __ Name __ _ __ _ _ _ _ _ j_e ��.���_ ^_� . .-. -"- , . .. . . _ . . I� by affirun fhat i am ezempt Eram the Contractd/s L�cense - . - , �- � ., �� �"' -. ta �or Hsg�pN�wcng're€tso�t'{SeetEor�703F.3.BdsinE3!vncf'"- A�de_g�;-�. � .0�-_ . ��._. _-.- .._, �=` .__� _:.._.. ...-:.:- -.._= ..._.-..y-.=... ,_--���l_�;� ' . .. v � _ Professians-C.ode� - . � � - - � i ❑ __ CiaY Tef.No. �7.�Q"L j � �1;as owwner_oi the propeny,wil4 do the work ond the . . . - . . _ - . . � sfructure is not intended or offered for wle (Section � � � �� . - �_ - � . � - . . � � 7Q44,Busines5 and Professions Cade). � .- - � � - - - . � � . ��- GONSTRUCTION LfNDING AGENCY � - . . - . . - - - - - - - . - - - �. - � . . . � - k fiereby affir m that tkere is o construction lending ogency for _ � - - . , . . -- � � . - . � . E - the performwnce_of ffie_work for which this permit-is issued � - _ � . � _: �- . ... - . -. ; (s�.aatx,��Y c:}. _ � €ender's Nama---. . � . . .- . � - . . .. . . . � � � . . - � . �. . LaRder's_Add�ress ��� �. .. . : . . - - . . � . �. .. .. � I eeri"Jy 3txit -C Keve�ead this appli�atian Qnd�state ehot the _ - � _ - - . � - � - - � ��' � above informrotion is correct.I agree ta mmply with all Counry - � . � - _ � - � ordinances a nd-S�ate laws regulatirtg Plumbing,and hereby - � - - .. . . . - � - ; ' aothorize represenr �ves of this County to enter upan the ��. �-- �� - . . - ' �� - � - � --- � . - I � above-mentio�ned p rty for inspectio�purpases. . � � � - � - � . . . - � . �1��r SEE REVERSE FOR EXPLANATQRY LANGUAGE t7 _ - fg. ture of�Permittee . . Date �- . . - - - - � . - . . . _ . � - . . � h O� ., +yao�.� . 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