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1199A
_ _ f ct '�� � WORKERS'CQMPENSAiIONDECLARATiON - - . APPEICATION FOR PlUMBtNG PEt�UIIT � - 1 hereby ofEi�m-tFwt I�have o cerrificatc of conaent to self :�y�b7A � - � - - _ insure,�wGCerti#itdtebfWorkets'-Compen5ntionlns�rance, .. CEgI7(REV.Ipigt)- .�' - � - . � _-- ar,o q��' d-mpythe��j�c. _ Lab.C.} � . . . � � . �� � t� �m CflUPlTY OF tQS ANGElES BUILDING AND SA�ETY , P�a-Tic`y No. � Company . . . ._ ._ .. . - - . -� . . . - Gerti£ied-copyfsher�byfurnished: ' ����- '� . . FOR APMICANT TQ€IEL IN(PRIIVT q2 FYPE) � - BUIIDfNG / d ' ! : �Cerikfied.cnpyis4ited:witlsthacauntyb�iidirxg-inspeo. � . AD6RE55 b � ; . tiont dePa.D�qpP 4. ._.��� �.� NUMBER- �. FlXTURE OR ITEM � �.. ..F{E ,�t�_ r - . . . : Date�i`��' li ant -�.WATERCIOSEi � -�- . �Z . . . i, � - - ' CERTIFICATE C7P E7CEMPTIDN FROM WQRKERS' BRTH FUB � _ � - � `"� � CROSS ST. . � . . � � CQMPENSA7#ON INSURANCE � . . . . . . . . . � . . {TlttsfYeN6rtAi�daM:�sianplfted'rfiltewo�kinvolredby ::� � SN4WER . OWNER . . � � . �� �1a parmii�is�for ont kerndnd�dolFan($}96}or I�sf.}- - - WVAFIX2Y . . .. . • � � }� -�� � �� � AODRE55 �_. .. / e..`LGI�..�. � . t cerfify fhat in fhe performance ot fFe work(or evF�ich this �� - ~ - . _ permit is issued,I sh¢E)not gmpkoy any person in ony manner - ���� � . - � . �"" CITY- `��e f'� � � IEL AKi.� . �so�as.to bemm��soh}sct to the Wwfcers'Compensatbn Laws. . . � � �---� 615HWASHER -- � � �' C6NTRAQOR . . ppt9�� �~� ppFisa[�#����•f-�� �.- ClOTHE5WA5HER �ip '� � AODRESS. � � .... � N`"`'CE FQ APPLkCANT: ff, aNer makrng thu Cerh4imte of � -� - -� � ption� you,-.shWid 6ewme subkect to the Wc�rk¢rs`, � SWMk4tt4�F[�tkECEFfOR . � .'.:-.. ._�- �.e... �- �.,._.w..,._ .:,_,.`TEf.Nt3.a. .,...._,.:_,,. . .�_,�. -_ �anp0e�satiort proriaions o�ti�e�6or Code.Yo�i must i-Qrfh-. -`, _�` rs `-__ .., .-: __ � w'rth tomply wi�h svch provisiorts or ihis permit sh61� be - LAWNSRRHJKtfR5v5TEM . . �STAT€� !''►( J� -.LC - . � deemed revoked. � ... - . -. WATER HEATER . . . �� LICENSE N6. ( f� f.J CtASS . ... - L(�NSEO CONTRACTQRS DEGARATIQ(V Df5TRK7 Np� .. PROCFSSEp gy - . � - t here6y.Cffirrri itu�k-t am-licensed undar�proviswns o�ChppteF 4 � � �� GAS SYSf€M-�� E)ttTlE#5... �.� . . . _ . . - - (cacnmencing with Sechort 7006J of t?�vesiors 3 af the Business - OUTtEi50vER . . .- � � ..�� and.Profesa�oits�Ctrde.and my:Iiceose if ia.f�it{c�ce and effesE. .� 5 P€a S�SIFM . � - - �` r� €rntaf ` � YAII AT[ON _� ticense Numb����� / . lk.ClassC�J� . .. . :� DATE f,:1%„�'�„ . .- � . .� � . ����!`�.. . . . . . . . - PINA� . . . . - � � :' Eontrac�or Oate �J . . � � &Y � - � - . � - .� Q._t pm exempt.under Se[:- . . . �. . . � . . .-. ... � W . . . . . . . . . . . _ . _ . R .. B.&P_C for this reason - - � . � . . . . . � Plcin check fee � . . � . �. .�� � - -Rtt1M6lNG PERMR ISSUtNG FEE E � - � . .� . ..� � < � Signature - . b 4 . � � �� � �.C!�i -� ` - _ . . .. . . :-. � iOTALfEE �Q ... . . _ _ . . � f .. . . . . . � ��s• .�.� t " . : . - - .. �. . �� - � Plon check applicant .. . .. . . .-� .__ - . _ . � � .. ... . . � `,� - SwGIE FAnntLY � - - - . . . � - . .. . - . . :f-� i',�,��� . .. � HOME�WhiEft-8F3tlDEf�6EClARAF40F�F -_-_ Name . 1�'� by a€firm that�i am exemQt from tbe-Goniroctor`s t�cansa .. . .. .. �- ...• ♦-s •I(;��C� -� .: L� ror tha fakiowtag re�on�Ses�tivrt 7Q31.5,Bus#ness arrd •'-.- l�dce3s:.-::,.t ,,:. .::. _..��..:_ ,_ �_f�: .__._�._.,._.�._.�:. .s._._��._, __��_. �,.,-, F. . '. . --:,�.. .::-'�� Professions Cade}-_:_ " _-� � City � - Tei.No. - � . ���}4-'�S rJ - � .. � _.. .- �' _- ---- _- _ � _ - . � 3.-os owncv-.s4 tbe pFoperty,wilF c!a the work and the -� - . . . �. . .. � -atructure ixnoi intended or offered for sale-(Sedion � � . - � . . �� ; �. 7p44.6usiness ond Professions Code�. �-. � ... ... .. ' - _ _ . . . � '�� ���. _... __CONSTRULTtOM LENDING_AGENCY.._... ,... --_-_.. . . � . - . . - . . . . _. � t hereby afflrm�ttmrthere-is a constructiarc tanding ogency for . � . . . � . . � . .. � � . . . € . the performartcdof ihe wwk for which ihis permit is iuued � � - �� - - � � ( ($ec.3Q97.Civ.G). � . .. . . � . � . � . . . � . � - . . _ _......_.. .. - . - � � - . . . . . . . - -�k - Lsnder'sName� . . . � . . . � - - . � - . . . . . . � - . . - � _ . . jg ,. LBndei s Address . . _ � . .- ..._. .. .. . . _. . � . - . . � ---.. � i t cer�ify-thaf t have-read this_opplimtion and state that the �� � - - ' � � - - . �' �� above informgiion is wme<t,I ogree�o compty with all Coumy � - , . -� - . � . � � - - . - - - . � - ordinaaces and State Iaws regulating Plvmbing,aod hereby - � � - .. . . . . . } aothorize represeniatiaes of this Coonty to ertter upon!he � .. . - � . - . f : -� obore-mentioned prop ry-�or-Inspection purposes.- . . . � . . . - � _ ...._.... _, �,_,_ ._. ._ _>, �`�w�� SEE REYERSE FQR EXPLANAFORY LANGUAGE ' - 'gn ure o rmittee� - �Date - - . - - .. .: � . . � � � . . � -� . . . . . . _ �. . . . . - . . � - . - � E ,;M '�:. .. ..�.; m � � ��g �,Ls, , .� -� � d � m � Q , fl.. � �.o. N o 6� � D mo , � T t. �L m o n'� ` . O-o r.f�o.rn m � r' . ,stm °'��o¢ � ° � ° � mo'Dm °' E �o .N .n v !n o �. m V� O1 L ..�'i yj.0 O E ,s�., D � '^ . . . . �:. p:W O C�'.Y - ,S',. p/ � p y}�` N t pi . 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