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1208A
3� , WORKERS'COMPENSATION DECIARATION � /�yPQLICATION F�� PlUM�ING PER�13' � j� I hereby affirm that!have o certifiwie of consent to selE �yqyy�p . . . ... ti insure,_or u c�rlifico�e o{Workers'Compertsation Inwrance, CE 817(REV.10/BI} . .. - . � � � � .. `3 - or.n certified topy thereof(Sec.380Q,tab C.) - � - -_ COUN'fY OF LOS-ANGElES � � �-BtISlD1NG AND SAFETY.- ,.p ,� � . poi�+va.kd/?.��3k�9F�� Q`a-4 � -. � ified copy is hereby furnished.. .. ._ . . . . . . �., . .FOR APPLIGINF TO Ftll lN(PRINT OR fYPE) A��d�E� L T1 ��a .��� �"���` i -� - CerliHed topy is€ilect with the county building inspec- . _ _ . _ I NU7riBER FIXTURE OR iTFM QG FE€ _ �... - �-�f'ron�depvrtment._ . . . . _ _ . .__ _�- fQULtiY� -�- aa�E�'�S Appti4anF�,hl d?E/'U �.L wnrEx c�osEr tZ "^ N�esr � ! .J � -� CERT€FtCATE OF EXEMPTION FROM WORKERS' �+. BAFH TUB -� - - � � ..- CRC}SS-ST. - �C U /¢ l7 E�f°�/ - � COMFENSAFIOPf fNSURANGE . . . _.. SHpwER�.._. . . . . .: :OWNfR Ju � .-. .-.. - . �� {T�ts wc1{ea naad aot 6e camplwted ii The wor[c fnrolrod by . . . � � . . - �1 y " . 1he parmif is for oM hundred doflors(5100}or lafs.) uvATarr �$ '�"" AppREss �a � r�K � . . . I certefy tYwi in�he parformartce-of�i6e�work�foc which this - � - .�. . - � . .. �permit is issuad,t shall not employ ony person in Qny manner � StNK �p ��— C�TY - �1�v�" i8..�NO. � sa as ta becQme sub�ect fo fhe Wwkers�Compenwtfon taws. OISfiWASHER � � b +' _ ( Dore�����a�pE�cant C`_ c�� aai�SwasHER � conTxaaaz t��"�CE W.APP€ICANT: If, afler makmg th�s Certif¢ate of � . ADORESS - -- =_Y_ - - - ._ -- S+KtAAMFNGPOBtRECEt+TOR ..:-� , ` .-: . �;. ,�:s j _ • ��.. ._ -- �1 �� � �tton, You:-shout�t,become sv6ject to fhQ:,.t�nrkera'._:_ .. . -:-. _ ,.�.-._._. .,.. .. ,.- , -__ . ._ p[P" ._ - lEl. NO.� . pensptio�p�trvis�orts o#�#heiuhor Cpde,Yo�must forth-� - LqWh15PRINKtERSYSfEM � � ...� � w'rth COmply with such provisionc w�this permit sholt be � � $T�+� - c E�. � - � .! ;�. deemed.revoiced:. . . ' - WAtER HEATER � �/ LlCENSE FVO. - �. p- C1P,55 ' - LICEN$€Q C6NTRACTC3RS DECE.:�RAfiFfN+t 61STRIR A�.. . - Wd0EE5SEb BY .. . i�here6y aHkm tFwt I em licensed under Exovtsions of Ckwpfer 9 � � � - � GAS SYSSFM: : �-OUtiE7S �.� .�. .}� . ... ... - . .�.: (commencing.wilh Saction 709Q)s�f�iris�an 3.of the 6usiness� . -OttTtE75�vER - - �� . t ._. . . . ..�-- ond Profess+ans�Ct�de,and my license i;in fuit forca anct eRec�. 5 pEk SYSTEM . � �` FINAI-�^�� _ {/J��,( /`jj0� _�. ��-f�i'�l�? - ��-� _��- f . _ ..: _. .. . ....� .. . DRTF�: __L�� � .. - . V � .license Number�. . ��Iic:Classyl=l�L,.� . .. -.. FINA � . - . . � 6L O €3 � - . M(C7 Vl�.l�4� Date �_S ..r� _ 6Y . � - Conhocirn. . _- � . . . � � . � .- . . U � �. . . . . ._ _ . . . . . ... .. . _ . . . . . �� ! 1 am exempt urEder Sec � � B.&P.C.far this reason . - P(IIn c�teC�c{ee � � � . . � . . � � - �� . � � . � �ee: P�ut�nsrruc a�an�iT rssuis�c�e E �O '� �i 2 Q$R ; . - Signo4ure � �_. . � . �TOTALFEE +2 V _ .. �.�f'�s�e � . su . ,-, �.- _. -� . ..� �_ . . Plon check applicont - � �- . . . . - .. . -��• P fi�Y�l - � � 51NGlE FAMtIY - ' HOMEOWMER-BUIIDERDECIARATION__... _ _.,--- Name :-- ,.. .�.. � ._,�..r_. �_ _- .. ..-., - - _ - -- �s� I� by nffirm thCt 1 am e�cempt from the Goniractar's Gcense�-. _ - ,�_ R�� `�G.� y `.: t� ror ih�-�alto+µit�g�easen(Section 763k.5,�6vsincss and...�. .: . �� . �.�-. .�.-: � ���. ..�. � G-7.�i 4-`.Cfi� . . _ . Adf,�rC55:. �4rbFessiartsG�e)r ' .-_� __-__ ._..__ _ ..--' City..__.. ._ TeLNo. . . . � � - ❑ . I,as-awner of the.property,wilt do�he work and ihe . . . � � � - - - � - � . . - - .. - � -- s#ructure is nW inlended or oHered for saie (Sedion . , _ . . - � � � � - - �- � - � 7044,Bu5iness arxl Profess'rons Code}. --- � � _ � � . . - � _ . � . � .- CONSTRl1CTION tENDtNGA�3ENCY__ _ . .. - ,..- � . - .. . � ...- � - �- Ihe.ebyufimrreFmttkere-isacorestructiontendingagentyfor�- . . � , � . � . � . . � - -� � -, - - � the�performance��of ihe work fw whick tkis permir�s issued. . - �. -- . . . . -� - � � � . tseE.�s7,e�u.c.�. { . Lender'zName , _ � _ _ , � . � - . � . . . -. . � � .. . . -� Lender's Addresa � � . . . . . . . . .. . I cerfify that k have read this pppiication and st6te thaf ihe� . � � � � � . .. , � � above'rn{prmotion is cwrect.i ogree to compty with ol4 County , . _ � - � �� + ' ardinances.ar�J State Iaws regulating Plumbing,and Fereby. . . - � � - . . � - i . outhorire.rep�esentotives�of fhrs Counry to enter upon ihe � . . � - � , . . - - � nbove-mentioned property f nspection purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE - � �-� "FS3� _ �'�.. Sig u of Permittee Dote � �-- .. ... . - . - . : .. . � � Tl �� ..� o o s , � � 4� � � � � � O o�ro a ���„ L ��L , "o_, � !^ 0 3 oa m o c � � � oi' ° , _ �o3oN�o �a �v, e+,'y o / �� ��w.°cw , °`` �mpm � �-a = u 3 � � fl c� � arn� c v ° � �- o p � ai o�N m a c � �r'-r s� `cr; E� �> � Z m'p U o � ° ° E m � �:n o -°a,° ii �,D o �o ao ~ Q .c�i.a N� m o r `a ��` ='4 F�,�'� o a m a ° ° � o E ; Q Q Q 'u � N O� P 00 d � E m T�_'H � C L S y�� a - . . . . 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