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1212A (6)
s. . � WORKERS'CQMPENSATtOMDECtARATlON-� � APFLICATtON �Q��PLUM�ING PERf�IT � -- I hereby offirm that 1 hove a cectiticate of consent to self� � �6pby7A � . . . insure;or o ee tificaie ot Warkers fompensWion tnsurance, �- CE 817(REY.t0lBI} � . . or a certrf�ed copy ahereof�SeE 3808 tab,C.} CQUNTY OF LOS ANGECES BUICDII+IG,ANQSAFETY �SY.No �{���fi`f�„�ny �i�����_/�j � - - � � ._ - _. __ ...._ .. -- ._ .._ -- ---— - - - .. Cecthied capy¢here6y furnlshed=:. - ' _. -. . .. _--- -- -- '__ __ . � � -- - ._. �..: �:.� ,., . _ ,. ._._ FQRAPPCtCANF-T6flQIItjPfFfIVFDNTYfEj -_ _6UItDING_ _- _._._ __ -__- .-.. ��rt�fiac#c�.iafilsd.withJhasou�tybvild'+nSinspec _. _---- - - ap6RE55��% �QQ _ 11� -__� ___ fio�depart�i ny �� . � �- NUMBER F�XTUR€OR ITEM1 � � F� t�'rr �� �� � oose 7''�-�`� Ap�f,4anr t9tt11��/�.!` -�+,-- �uaTER,a4�x #,•- ----. ._._. . _ =-t�. .. - ._ - - - - -- - -- --- - -- - -. �y �-_ .__.._..NEARESI-:�- -=--�-- ---=- _- __�_ ---- ,',- :.-CERTlFIG1lTE�EX€AtiPT16KFtiC7NlSh�QRK€RS- ����- .4�._. $QTli7UE_ . . -_. ._ _,�.. CRO555T.. . - - - � .. '' --CAMR�AISR.Fl9Pkih15kiRlCA1C� �--'�� - - - _- . ,_ - _ - -- �- . .-_- ..- -. � ` _ _..4YytiEE� - - (Tki:sectfcir aeed�t bc compEotad iF tE�f wark iwral�wd bp - - �Q���_ - - -- - � - � -- -� � iha pecmN ls For oae t�vadrod dcUors(Sf00}or lou.j ., tav�FOav� - - -- �a L�'f - - '�.- . - F.ce�lify�hot in-the perforenance a4 she wo�tc far�whkck thrs aDouE55 -� �� .� �' ' ."- . . . ,.l:.riraF�� - �. ,. - : . . . - � .. w as io 6ecame su6�ec+ta�Me Workers'Gompensotion Laws. -. ;�,� � . . �''y"`������`��� � . .��.. - �/ 61SHWASHER �� -- ""� CQMRACfOR . - .. . _.� oate�—.�—rftiS nrP��ca.�a���lts � c�or�s wasr�a ,,,,, y�,p I R„''CE TO RPPLFEANT: if,-aher m�keng this Certifimte 4f -:- ---. ��� . ��vk� -- - � ption, you�_shauld isecome su6ject to tha,Workers' _ __P��R - � . -. __, ,;,, . - Co:npensotion{xevkionx of--tFie tef�or Code you musi forih- ..:_: __ _.. - _. . .. .-�: - :� , . ._, ..,,�.,_.: . ,e....r,r _ . .::„�, SWIhWitNGCIXXRECF'-- --- .- -- �'iH.No.'.. with�compty with suth proresiwa5-ex fhes permr#�s1w{t 6e wWNSPRlNKtERSYSTEM � , STk4E � ���� deemedrsvoked.._ _.__ __.- _._ - - WAiERHEAtER . .�v lICENSEN6. . - . , ilCENSERCAPFfRRC76RSf}€�tARRfif�F*k -. -� -�--- -..._.- __.. _ � _.._. . � ___. . I herehy af#irm that!am t�cenaed�nder provisions af�hoPter 9 � Gk55Y5TEM .� OUSCEfS �s �.. DISTRKT ryQ� ._ �SSE6 8Y � � f G" (commennr�g witb 3ec�ion 7ppp)of Dlvision 3 of the�Business OUttEtSfN�€R - . . . - . andProfessinnsGode.andsEg.licsRueisia#utl#cxcaandeffen: . : saERSrSiEM � ... � . � � . .. }- . !i ` - �} - FINAL� � V1� DAnQH �" _ . License Number-�i �'I�]� Uc:Closs.�,� .. . . .. - . - � QATE ��_ t�L-�,. . . `. ..�...� -� . . ��/.L f�Q�Duie `-r':����� - � . � - -� B�Y q _ -.,... � .._ , . Q � ` � Connpeto� : --�: . � � _ . . � . . . � . � . . � - t am exempt under 3ec. � � � w , � - B.&P.G.for lhls reason. . . . . - �� � _ P1an check fee Z # �121,eA : � � - Dnte: . . RMI7 I55(TING PEE$ . . � . . � . Signoture . . . - �� � � �-o� - � � - � - .. -� - _ _ ... . . .. PLUMBfNG PE. .. FQTAL FEE . .:$Z � . .. . � : . . . .--. i . . . . . . . Ptan thetk applicant � . . . . � � -. � � - � � - � •-:'-���.rl Q � -. .�_.� . . - - .StNGLE FAMILV . . , . . . . - -.HOME OWNER-BIJILDER-DELEARATION _. .. CJ�ame_--- . - i ° °�%..2,_CJ G U.__....._-_ �` by aKirm that I om exempt feom the Contraetor's�lceense ... ... . � -- .. . - . -. �-tk.- rorthe foPiawirtg reosar��(Secf7oK-7031.5<Busincss and `-" Addiss6-.��-;- , � - _ _ . . .{j.%,(�L�.,.��:�. .. _.___ - �Prafeuio:sc Code): -. � . . - CiiY - � -Tel.Na. � . . . . . ,.. ❑ ..1.as owrrer of Sk�e property,wi14 do ihe work-an!i the . -� . . . - _ . . _ � . . � - . . � �tt�udura:-is+hat-[rrtended�rr affered far�sote(Settian-'. ... . .. . . . .. . � . . .. . . - .. . -. 7044,Business artd Professions Code}. . - -. -. � . - -- � . --��-� -� -CONSFRUGTION LENDING AGENCX ., . - . . . � .. �- . . - - � -. � .' -- � - � ... {heraFSy affuin fh¢t tk+ere�+s aconstruc+inrt-lend'eng c�genty far �-�. . . . � . . - - . - . . . . . � � �. the perfwmance�ci the.warfe�-for�wFsic�i-ilvs�urtit is lssuecF�--- -_,._ __.---_ ... � � � _ _ , . (See'3097;Civ..C:}. . __ ... .__ ..-- - --. ._ _ ._._. . . . . . . . . . .. . ._ �.Lender's Name_7.. � :-.- �._:_- .:-_--._ .... .. . . . . .. . . _ . . , . . t . .-.._ . . . . . , . _ . . . - . . .- Lender'6liddcess�`r. ..�-.. .;.-,.c . _,_�_;:,_' . _._. _ ..__�.-'-._ �.__.__...... .�_ ....__:_ .._..__.._- . _,:� . . _...___ _ .�.-- --------_._. .. I carif;i tkat f-hmre reod.thi:applccotian aad xtafa.ihat.the .. . . . . . . . .. . . � . ..-:- . . � . , above.:infwmation�sconect..i.qgree�tosomp��withc�tl-Cauntyr_ .. . -. -,- --.----- ----.,- --_.--- .. ._. _. . . . __ __ ordin4nces and Sw�e lows reyubtim3 Pivmbirn,y,vnd�,hercbq . - . . � auffior(ze ropresenlfltives,of this,Coonty�.to enter uppn the . - .. -----.. --.- .-. -_. . -. .: _:� . _ �.._ __ _._ __. ._. � � -: a6ave-me�honed�property ___inspectEan purposes. - �� � � � . � . . . ._ � �`��� SEE&EYERSE fOR EXPlANATORY LAPIGUAGE - � -�. 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