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1208A (6)
3� , WORKERS'COMPENSATION DECIARATION � �PQLICATION F�R PlUM�ING PER�13' � j� I hereby affirm tha�!have o certifiwie of consent to selE �yqyy�p . . . ... f insure,_or u cerlifico�e o{Workers'Compertsation Inwrance, CE 817(REV.10/BI} . .. - . � � � � .. �3 or n cer�ified copy thereof(SeAc�360Q,tab C.) CQUNTY OF LOS ANGElES BUSlD1NG APID SAFETY � t�� Q�+�.kdp.���k��, � . 7� ified copy is hereby furnished. � � . .FOR APPLICIIMF TQ Ftll lN(PRINT OR fYPE) A��d�E� L T1 ��'a .��� �"���` i -� - CerliHed topy is€ilect with the county building inspeo . _ _ . . I NUMBER FIXTUREO&iTFM C� FE€ - �... - � f'ron�d(e'pvrtment._ . . . . ,�) _ _ . .__ _�- fOULt7Y� -�- � . DalE�d-S Appli4on{�"1,��.E!_V . �.1.� WATERClOSET �� �Z��^ NEAREST f ! .J . � -� CEftT€FtCATE OF E7(EMPTION FROM WORKERS' �+. BAFH TUB -� - - � � ..- CRC}SS-ST. - �C U � lJ E�f°�/ - - COMFENSAFIOPf fNSURANGE . . . _.. SHpwER�.._. . . . . .: :�� � .-. . -.. � . (T�ts wc1{ea naad oot 6e campl�rted ii Ths wor[c Fnrolrod by . . . � . � - MA11 " the pormif is for o�hundred doflu.s(5100}or la.s.) uvATarr �$ '�"" AppREss �a � r�K � . . . I certefy tYwi in�he parformartce-ofi6e�work�foe which this - � . � . � . .. �permit is issuad,t shall not employ ony person in Qny manner � S�HK �p �� �� �1��/�" �""��' � sa os ta becQme sub�ect fo fhe Wwkers�Compenw�ion taws. OISfiWASHER � b +' _ ( . . � CONTRACTOR `� Dpte�+����`Tp{icanl � � c�b C[OiHES WRSHER � r^qppRESS . _ _ t��"�CE TO.APP€ICANT: If, hfler makmg this Certif¢ate of �������� :.;- � -- .-.. � .-. - _ " - -_ - _ . ���: �: -: �� �tton, You:-shout<f,become sv6ject to th�,.t�nrkera'_._ -�,-. __..�.-._._. .... .. .. . ,� ..: . �..v -- - - — -- -- CtiP` � iFl. NO. :.,i .. �. penspt�o�p�trv�s�orts o#�#heiuhor Cpde,Yo�must forth- LqWMSPRINKtERSYSfEM � .. .. . . .� � w'rth COmply wrth such prov s�o�s w�rhis permit sholt be � � $T�+� c E�. �� . . ;�. deemed.revoiced:. . . ' - WASER HEATER � �/ LlCENSE FVO. - �. p- CtA55 � - LtCENS€tl C6NTRACTC3RS DECL:�RAfiFfN+t 6�STRICf[�.. . - Wd0EE5SE6 BY .. . . I�here6yaHfrmlF�tlemiicensedunderExarisionsofCkwpter9 � . � - GASSYSf{M: : �- WtIETS .� .�. .t� . ... ... - . .�.: (commencing.wilh Saction 709Q}s�f�iris�an 3.of the 6usiness � OttTtE75�vER - - �� . t ._. . . . ..�-- ond Profess+ans�Ct�de,and my license ia in fuiF forca one3 effec�. 5 QER SYSTFM . � ' FINAI�� � _ {/J��,( /4,jj0� _�. ��f�i'Fl�? - - _ ..: .. . ...� .. . DRTF�. ��, f� .. . . � � license Number� Iic:Class�� ` � � _ _. . C` . _. . .. FINA � - � - � O Conhoctor M(C7 Vl�.l�4� Date �—S •.�0.3 . � 6Y . . _ .. � � - �. . . . . . .. _ . - . ... . . __ . _. - � . u� � � 1 am exempt urtder Sec � B.BP.C.fa.rhis reason P(an check fee � � �ee: P�uMsrruc�n�iT rssuir�c�e E �O '� �i 2 Q$R � : . - Signo4ure . . _. . � . �TOTAL FEE �. � � _ .. �.f�s�� � • �v . . -- _. -� . ..� �_ . . Plon check applicont - � �- . . . . . .. � . -��• P f1 t���l - � � 51NGlE FAMtIY - � '� � HOME OWMER-BUiIDER DECIARATION.._._ _.,--- Name :-- ,.. .�.. ._,.. _. ._- - ..-.. - - _ - -- �s� ._ �.� _ _ .. .... . _,. ' I{" by nffirm thCt 1 am e�cempt from the Contractar's Gcense�-. -- - . - '.� ".'�- ,`_ 'R�� ._ . . .. •�u G.�'t y `. LL ror the-#olb+µiog reasen(Section 763k.5,�6vsiness�and...` CAddress._. .�,. - � Te._. .�.-' . . G-7.�i�!'Fi� " �ProFessiansG�e)r - . .-__ ._.._'... � ty � _ . � . � . � - . . � O L No- . _ � . I,as-awner of the.property,wilt do�he work and ihe -- s#ructure is nW inlended or oHered for saie (Sedion . . . . . . - � . � � - - . � - � - - � 7044,Business arxl Profess'rons Code}. --- � � _ � � . . � - � _ . . � .- . � CONSTRUCTION tENDtNGACENCY__ _ . . :._. � - - . .. . _ ...- . ,.. Ihe.ebynfimmeFmttkere-isacorestructiontendingogentyfur - . � � � . . . - . .. - � the�performance��of ihe work fw which tkis permir�s issued. - �. -- . . . . -� . - - � . ` tseE.�s7,e�v.c.�. � . Lender'zName , _ � _ _ . � . � - . � . . . .. . � � .. � � Lender's Addresa � � . - � - � � � � - - I cerfi4y that f have read this pppiication and st6te thaf ihe� . � � � � � . .. , i � above'rn{prmotion is cwrect.i ogree to compty with ol4 County , . _ � - � � + ' ardinances.and-State Iaws regulating Plumbing,and Fereby-. . - � . . - � � - - � � .� � � outhorire.rep�esentatives�of�his Counry to enter upon ihe � � . . � - � � . . �. � - - nbove-mentioned property f nspection purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE ��V��� � �'�.. 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