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1223A (6)
'.58 WORKERS'CQMP€NSATtON DECLAR.4T�QN . � �pp�,�eATIQN FQR PlUMBIW�G PERNtlT � � . I hereby affirm that f have a cerffficate�of consenl to self �yqybTq - � � . . � - insare,cr n tertifiwte of Workers'Compensatian knsuronce, CE 877.(REY.IaBlj � -�- - � �� . � � - � . o❑�n d copy.oher�jr,�c.3900.Lab.C.} � . . .. . .. _ _ . -� '�-�� COUPITY OP LOS ANGELES BUltQ1I4G ANQ SAFE'fY � t��f - P ii . . GQmpany i„[!'��I�"IQ:�S . . _. . . . .._ _ - O��� _ . � Cer#tfied copy ia hereby..furneshed..., � ----- --- -�--� -�� �-�-� FORAPPt�CANTTQFtLUtJ(PRIN70RTYPE) r'1 ..__ _.._... . . __ .- �Certefied copy�s filed with the courcty buildin9 inspec- .. ADDRE55 W � - NUMBER FIXTURE OR IiEM �aat�n ftOY1 d8¢RCkmeiH_ _... � FEE - � '�] �l� WATERQOSET . ` i�- 6ate_•V�AppT74ant/TZI�Y..� � - - � � NEAREST s . -�C€RFtFtCAiE6F-EXEMPFIONFR4M"WORKERS` _ �L'�� BnTHTuB - . . . � , CROSSSF. . (f . �'. . � . - ..CQAIPENSAFION INSURANCE � - . - .� - � SHOY¢ER- . QWNER - . (ibia sectlon�naed nM-6e�t � - . bY.:--. . ._� . � MA� .. � .� ♦ � . Y � th�pe[mlt.is for on!14�r�drvd.doFlars'(S10Q)ar 1sss:I � tAYAtORY � � �—' n�oaEss '� . t ce�tify ihat in the perfarmarnce of iha�warfc for wFich tFris � - �p . . . - ' permEt�.s�sured,.t-sl�ou.aosemv�Y-�`Fe��so*,-,m�ny-.+wn.�e... . �L._ surK. - - � y -� c�rr �_[- ,� � ' - rH.rao. . ' i�Fftfl - so c�kt.6ecoma�ulz�es#to the�Wcttkars':€cmpsnsat'ran tuwv . . . - . . '�� .. � . . ._ __ .. DISHN[ASHER .-.f_ •r__CQNFBACF6R � _ . . . . . ,Q ..__ . . .. n�,���-:�-$S`d �.. _ -: CCI�`l`� � �,:kcs,nz c�o€t�swa�s�� --- _ �4 '� anoaEss �''"`CE T9 APPkEG4NT. If. after makiA4 th3s Ce�tit+cate af Swrrovattt�K'r�P9Q1 RE. r� �.., .,,.� .,..,.. .,:„. _ g.. .. .: ... . ... . . � ptiiaw. You-..sFWUki-l�BGitnte SuhjeCi Eo_.3Ere.�Nisrk9rr` - , "> . ��?aA, � . . ,.-� ., . : . . �:,-, � . Com enwtian � .. � . . � c�rv :. � T€t:t+�. � p provisiw�€uf.rFie lubw�-Cacfe.you musr fwrh- tqwwSaRErtKtEssrsiEtn � .. with comply with such provisions or this permit ghatl be - � - SfATE �j + .ttC. � � � deeR+ed revotced.� � � . � warER HEahrr - �rcfNSE No..�j ( Q cwss . .- ,. LtCEN5E6 C6h1TRACTQRS DECiARATI�[1 - ot57kl�i NQ, � - PR€,fEE55ED 6Y � - � .. (hers:byriH�tm_thatto�alicen.saelu[rdet{xeaei&en�erfGhapter4.. - GA5_SYSTEM ��QUIlE7S.. ..� . . .. � .. � . . �CQlRRf@iiC�R'i�Wtih.�f Wh Z�Q��F{�IVISfOf}�O�1f1�-�Si�1CS5 . QUFLE?$OVER . . . _ nndPr�€ssswnsEode.ondmy�l�enae€t6nfu41fvtces�deHecr. . .._ S�ER-SYSiEAt ---- � ..__�___ _.._- - -__... ....._ . . . } ���� _._ Ftnrnc Y tlDAfldN °- _ , ffatf¢;` t:F ���, p - bcense�Nurtrbe �ic Class . • . . y . . . . t � - . ���" `� .. � � � .. .. - FtNA�_ - . . . . _ ft. . -CoNract Date�J�---�C� . _ . . . gy �'�.,�._.__„�...._. . . � V . Q- f am exempt vnder Sec. . .. . . . . . . � . � . � . - . �.. � �B�.BR.C-For ih�s reoson . .. . -. . � - � . . . . � - �; � Plars check fee � _ Z .. . _6ate: . . � PLUMB€NGPERMITlSSUINGFEE � { � . � .. . � .� �_.SignatuCe - - _ � l� C _ . , � 2� [[:�J!� . . . . . . . - ,..� .. - .... - . .. .. r.TO7AlFfF OQ 34� . . - . - . . _ . ...��: i•.•a�. .. - ��- � . . �� .. . Pivn theck applicant � .. . . .. . . . � '-_ . - SINC�LE FAMfEY . . . � . . .. . - � -. . . . .-1 • 1 G Q 5 0 . . � .`...,�:HOMEI3WN€R-6lHCDEROEL'tARAT10N-,�---.. ..... . t+lame. . . . .. . .. . � . . . . � �gafhrmitffitlamexempthamtheGonnactw'slicense . _ .. . � �;_��;=�u,w� ..� qddre�s�.�.: ._, �._-_i ., .--_:a >.=�a . ...' ,...�. ,. <t.: , _ :�.: ..: .. _ �,�' , �_.�'� . ,. ... - . t�. ror ifie#otlowing`reason-{$ecfiori`7(13T.5,_Business and __ . - �g_���v� - Professions Code�: . . . City . Tet.-No. � � - . � ❑, I,os awner of tha property,witl do fhe work aritf the . . .. � � � � � -- -- � . _.. - s�ructura is not-intended or offered for sale (Section - � � - , . . - - � � � - . - � . � . - - . , . � . . 7p44,Business and Pmfessions Code). � . �- . . . � .. . : . � � ' CQNSTRUCTIQN LEN6tNG AGENCY . . . . . .. , . .. . . . . . . . - f hereby offirm.that-xheraua cansiruction tendiug-agency tos.. . � - . : . � . - � � . . �..� . . . - the�perfo�mance af ihe wotk for which ihis permit is issued . . � -- .. � � �- � - (Set:.3F�1.Civ.�C:). � - . .. .. . � . - . . - . - . . . - . . ... � - . _ . _ . . . . .. . . _ , . - - - . . � Lendec'slvame _ __. _ : i __ __ ___ . . . -- � Lenderts�e�ddteu � . . . . . . . � . . . ..- 1 cerlrfy-lhoT Thove read this appticatidn and state thaf the . .. . . . - .. .:� � .. . � .. i abave infarmotion is correcCt��ree t�scb(tsply-with-qt�-Coumy=-:� - - � . � - - � . . - � . � � ,, .- ordinarttes and Statelaws regulaterg Plumbing,and hereby - - -� - .. � � � - - � . .. � authorize representatives of this-County to enter upon the - - � �--� � � � - � . � . � � above-mentinned property r inspedion purposas. . - : .� . _ . .... . . . . . . . . . SEE REYERSE FQR EXPI,ANIITORY U►NGUAGE -t �- 5� m� e o Permittee - Dote.- . .� . .. � . . � _� . .. � . .. � "�� , � V, ^ ._t.: � 0+%� Y.\ ���c � n p c , ' �.. N O��` 6 ✓�-..O N�n� Q � ,.. , . , �, +�" m o � fl-c � `�-O � y� '„ , N ��N N .+p �i p-a C p � � O '..bi ���LG 01 £�� .. ... `r '. . 'O"L.DNNOinC��LN � mY•-01ffj~ 01O �G� V � y' �n ' _.•:a�,;>.E o� p G c C° '" >_ x�o s� � �o ia,o N ' �.","' �o �c"�a ` ��,,m o 0 o m c �,o'.0 0 C'p,?y a o �-" oam,�,°N•o�� �.ops `,�� oof ; � � �„ a� c U ° � a a.a c �a � � „'� v � � C=,t y"p a. ; N p O�..L v T�-n�. �O.� d y �£ p �i'� � T N��=. O-fl �- U y .O - , } � i p y 'i� � 6� r'�'fl-C1 C �'� � ,, a . d �3QOV �. w ` � �d� QO••- p0`�� O+�DpL r � . � . .. � , .,- o<� °R,,�� o E ° c a`O`�o N� L; >� ' � � m' � ��,o. � a,� ° °' o°o m c by a�o°-a °s >f G � �yy � .� O��N u �.,y,_• �� a+� � 'L p1 1,0 � �'O-p p,� � � r , i� G'O �- ti 7� C Q" .T. O Q j 01 +n p, r. � Q ' m3 ° � a,aa'� o '"- E o._ 4s,.�''M-oEo � �3 E Q. o .. �.. o Nc �'"'mS =L%-"_- c mo�� 3 ,,�-"' `a� ` � " � p"..�° o °v ?�,o" c �o o � 4°- "3 ,�,�..,,�' ^D' °m o m�-�o u.+ o. � �/� � J. y� Q V'� � C L"O D Q CY N'�N E � lI m o s �, �C'fi�-' �° �c>or� m L'� E m >'� � �., otf G� �„ ,,.y o '^ '"=, o m o " ,n �-��"� w 7 s-c o m.c' U .� 4� � 7".�•r�O 'fl 6.��s 04 O On � a� a u`Sx�C ��� � � �. � :� 3e4 ..''° nucuS`^. a ��OD �`3 - .� . �". `. o d w �,o's�s o o � �,,c o .y v,�+,... _ p7: mm aN +j,' �c� 000,�'o r, .41 � � ? i.�;t Ol O N in"'P" '�4,1'� ' `��mtlo�EV �l . ' ,.`', , . ' �: 1., 1.;, \�t11 "1 � �`l` ; t',` ,�,1 O ,�11 2 � or `��, � _ .W . �' S, .. . N ,1,� 2 �q � ^�' � r . . - ..�w", �� . .,�,� �: i . . _. , �� � ' �. . �. �t�', . . � � � r��, � . ��� � � r�.r , � . a",� Z a ' >• +n a f � ; � � �� . , . N `� � -�' �' ��';y � � � � `�r' .� o 1 Z �� . � ��� C `,� \C1 . � �1q r � � � r ` � � p �' W 1 c,a �� �., i � : � . �' �� , 7, _' � � : _....�-�« ' `i � `. 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