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, - � `� � - -WORKERS'CpMPENSATtON-pEC1ARAiIQN--- - . p�PPlICATIQN �QR PLUMBiNG PEFtMlT� � "° � � .. �k here6y uffrm.that!haee a certffimta.o#cansentto sel� --76A6b7A� .. . -. - ensuro;ar a ceceiNcate aE:Workers`Campanxstlon 9nsuronte, '-�CE 817(R€Y.t0/81 j � . . - . or a�certifred eopy therqaf�($ec.380EY,knb.f.} - . � � . . . . � . CQUNTY OFLOS ANGELES� BUItD1NG J4NDSAFETY-- r- PQalicy No. . Lompany . . � . . . ..- _ _ . . .. _ .. . . �Certified copy is Irere6y fumished. � - -� � FOR APPIICANT TO FtLL tN(FRINT OR FYRE� ����' � ' . '�Certified ropy�s fited with tha cou�ty buitdl�g�inspec- -� . - - ADOR65 - hondeportment. - NUMBER _FlXTUREORtTEAA - Q FEE � - . r . .... ���� / ,I� LOCAtlTY - � � . Date. �y� (+r+t ���'-^�^'w' J WATERCIOSEi . . .. !� � : aPP�+t .___._ _�____ . V v h�,4RE5T �:t .. . . . � . ._. �CERTtFIG4TE OF EXEMPiiOfY FROM-W6RKER5` ..- - Z^ 8.4TH N9 -- -� �� � CROSS SF. � - ; - � COAAPEM1ISATI6N lNSURANCE� .. . SHOWER . - � . � QWNER - � . . . � (Thts saetioe e�ed eM he eamplatad[f Nre work.lmrolrad by - � � � . H�r pera�it Fs hr aw lwndrod da0ar;(St�}�or.less•i � � .,,'�. LavarExty� - (l'�� aooRess '���{ � . . � _ . 1 certify that-in.ahe psrformance of the work far which this " - � - � � � � � parmit is issued,4 shakE not empfoy any persan in ony-manner � �NK � - (� CI - .� ; TEL�.ry4, . � - sa as to 6ecome sub�ect to the Workers`Compensatfon LQws. � DtSHWaStiett � � . . � � - �� � -� . CONTRACiOR ' �ate �� Q��licaRt - - -- QQRiESWASHER - -. t' TkCE.T6 APPLfCANF:.tE;after makirtg th�s Cactifimte af-��. -..-... . ..: :. �E� __.� _ -.�: _ _..: ` = , `--� - 4 �pticrn._Ycsu..chaukd,t�a€ome sutaEecE--ta the�:�4ilsufc�i =-S�MMM�NG�F�a€cF}+XSR -_- ..: ..- : - - ..'. -:-..--� - - Gamperisatton . _-. - _. . .:_ . -.- . ._ -- provisiorts af ihe inbor-Gode,You mosr forfh- '�itt . ._.� , .; �_ t£t.Ma. .. �witfi�comply with such praviseons�or.this permit sfrall be - �K`NSPR4NKLERSYSTEAM1 . -� --� SFa7E - -- - � �{ tIC. - dee»ted revOked. - . � � : � � - - WATERHEATEft . - � � [�fENSE NE7.�.1 C{/4$$ . . . . � � LFCENSEQ CONTRACT6R5 QECtARATION . � - p��� � p��y B� .. ( t har�r effrrm lF�k I fem licensed uRder pr€fvisior�s Of CEiapter 4 � GAS SKSTEM -�6UTlETS . ... .- .-j�- ..� . . tfR f F (commencing with Sectiort 7pQp}of Divisian 3 of the&tstrtess 6U7tEt50VER �� f �.� wad PrafessRRans Coda.�nti my.licens�i.�rn fult face.and.effect� - 5 PER SYS� _ _ ._- ... �_._ .; - . _ ?� �r�rac vauD1iT18N � _ . (_ . . .. . „�i,! .,.:. . _. .-. - . .__ 6A'fE tTt._�`� '°`�.'-Y'. ... �� .� Q � � License Num6er�����' Lic.Glass�—31�� -. . , � - . . . . - - HNA��-.----�--- ��.'--- .. . - . � a.'. � �� Corttractat- 6afe��P`��4�� - - �- . . . - BY . . . - - F. I e � � - ❑ t am exempt vnder Sec: � � ---. . . . - . . - � � . . - . - � � ur i _ � . ... . . .. . .. . . . . . . �,- :� ._. . . . - -.___... -----_. _... � � . . _ . - B.BD.C.-for t6is reason �� � � � . - � � y P[an check fee Z � . . , . ... - Ootr.. � � �P€UMBING�PERMIT lSSUlNG FfE 5 � f� � - - . . . -� . . �. ..:-.. � �—. ; . . Signoture� . . . - . . F _ rara�.�� �0 1 t�6 A I .' . . . . . . � � Plan chetk appficarst.. . . . . . . � . � . � -� , �..��f,�.i� ; � . � SINGLE fAMILY � - - ... . . _ � � . . � � � � . - HOME OWFJER BU4L6ER DECLARA710N � �. Name �� . � -_- �. - - -- i., 'eby affirm ihat i am exempi 4rom fhe Confracior'glieense ,� , .:�� ,;y, �. ,.. , �::� .. / -- � �ra��.`J� Addrass--� '�`�•�� � ^ ' - __ . tuw�fc�the fvttowir�g teasar�-�{�ecr'rcx+'-703t.5,�osmeu aRd,�� . •--�- � ---. . " ' .' . . . ._ ..__ ..... ,,. _...�;._ ".a •���t�� 3 Professions Code}: � - - Gty - - Tel.No. � � � � _ ��•-I,-css owner�ef-the property,w41!do-tbe work and the - . � _� . - . . , � _ - - . 0 6.1.l��� � _ struthue is not intended m offered for sole(Settion � - - � - . � � .. - � � ,., � 7044,Business ond Professions Codej. - - . � - . �� - � � � - � , F . . - _CONSIRllQION lEhtOlNG AGENCY � _ . . � � � - . . -- f .� I hereby affirm tfiot there is a mnstruction lending agency for . .. .. .. .. . . ..- . . .-.� . . . . . � the performwr+ce_ef the wwlc-fcr wkicb;rhis peFmFt--is-'ssued-- - . � . .__ - . .- (Sec.�4T.Eiv:C-.). _ � � � � � � - � , . _ - .. . _ -:- -. -. : - . - _ . . . :_- . _ . . . � . . Lender's Name-_.. _ . . . . .. � . . . � . . � � . .-. . � -. . . � . . 3 .. ._.. . - . . . _ . . . . . . . ... . .. - - - - . ...� � Lender i Addreu .. . . . .- . .. ' I cerlify thpf I hove r¢od,this appEimtion and state that the � . . � - - _ � - � � � �� . - � . obove�iniormatiocv ls cwrect.I vgree to cwnpEy with atl Cou�ty." _�.. . - - - . . � - - � � � - ; . o:dinances.BDdState tawi-regu(at+ng�Ptum6ing,-b�d hereby - � � - - ���� � -, . . - � - autharizs-representutives-af�khis��Lounty to enter�pon the � �� � : -� .-- � - � � � � � a6ave- ntiwaed properry.. iaspectian.porposes. . . . . . . , . . ; SEE REVERSE FE?Q EXPLANkT4RY iANGUAGE : b-t� _ �.- Si �fat• of Perrnittee . I}are - . . - . � . _ � . .. . -:�_: �:_:.._ .:.:_: .�._-:. _-.__. ._-----' m � '..' u � .�j C Cns s . � .,�.. � �n G "'"� � :/" 9'V �D��T, 0...n . .. . � � � �a- ° ti m w � T». m °� o� ''� u °'°v c.n arno \ a .n u't'.�n d O � 0 N N tU L ?i L � O � ,L„O> �, ' , o�30 �°nro��-�o�o„ � F�~ ct3> m o °'O �', o� crom�„ � „ ° ou� � rowo °� ¢mocod. �, 0 o p m �'^ o� v �'�n�� %'�v o ° �o �..a, a"� '` E o v m�o��mm$?my». m T�p7-o ��� o� o�,�� � \ � E c� E � Q oa d� �m � °�.o�°'o.y Dm s�` . �9� .," � Q o o �,. _ mt aq �-Q o p � t.„ , � p N . � . .. 4 � �4,o` m ° .�ac o ro �a c � �`�� � >dY�Os m2 G � � . � . . O- • t1 u�U r� x �..p.O t G K �^ O'9 ... 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