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0765A
; - - WORKERS'COMPENSATlON DECLAkATION - ^. pp«CATION�FQR Pl.U1ltlBlNG PERMIT- �� - - � � � 1 hereby aHirm thot t haYe�a cerriftcate of cortser++to aeif �yq�Jq . - . . . . j , msurg,�w-p certifimte af Workers Compensation Insurance, �� CE�81J(REV.16/8t) . � - - - I or o cartified copy�hereot(Sec.38E1(I,1a6.C.) ._ CQUNTY O�LOS ANGELES BUFCDING ANQ SAFEFY � Policy Wo.� - �Componp - - . . . - . .. _.__ . .. . . -� Gertlfied€opy is hereby f�mished.- �� . � � � � - � _ � . - - FQR APPtICANT TO FtLL!N(PRlNT OR TYPE) . p�RE5�.5 � � � � �Certified capy is fited with the county building inspec- , - r � hon department. NUMBER .-FIXTURE QR ITEM [o? --FEE �� � - t / (r� �t LQCA€!N� � E .. ppte�0~l-��l"���RPPti-yant .. �---..WATEHCE45ET_ � � �l+ � t�A2ESi � .. � . € TE � . - CERTEFICATE-OF EXEMPTl4N FR6M WQItKERS' � . .7i"" �AiH T€16 � � t CROSS SF. � . f,. : . - COMPENSATION tNSURANCE- . . . . - - . OWNER . . . } � .(ihh aaetioe ae�d n�6e metp�etsd.�Uw work inrolYed hy - .. .. . SttawER . . . . . . . . t � tha pacmit is 4os.om hvndr�d doilare(Sf��w{ess.} . - .Z� � VcvnTo2v � - . -�,. � AbDRESS ��� � _� ' .1 certify.thae in�he-performance of tha'wark for which this _� � . . � ��� - � - -- � . , . permit�is issued,4 shaN not employ arty person in any manner � $�N� � � - � - � �� . . �TFL NQ• - . � sa as to became su6ject to the Workers'Compenwtion Laws. � � p�5ttwa5ffErr � � - � � - � � � � . . . . . . COMRACTOR � . p � Dqte - � �ppliCant - CiDTH€S WASN€R . � . � . i { "ICE T6 APPLtCAPlF:tf.sfter�rt�pking:;thy Ctrtificate of �.-. -..._ - __ -A��R�� - - -- -_- _ -:-.:"�.{ � npiio�r, yau��st�ucAd�6ecame'iubjezt�a�the-Warkers' �, . ' � �IG:PIIE�€REtEP� , .,, :,. -:_. � :- --: - .._ ._. . . ;_.__.� . Campensation pravisfans of the tabor Coc}e,you must feAh- � . GlFv 7�.pap� - w�fh complp wfth such provisions-�ar this permit-shaft be � �wt�s€7ttt�nctERSVSiEM S�A� r� L� � deemCd revoked. - � . . WATER HEA�ER . . , � - �f����` EtA55 � . : �. LECENSED CONFRACTORS DKtRRAT10N � . . - DISt�tiCi t�K? .. . CROCESSED BY � I herebp.affrcm Niot f am bcensed underprovrsiorts of�Ehaprer4 .. .... GASSYSiFM . : Ou3tE�s�.� ._�.�p �. ... . . /�:"_ �. .�.. . ... - . __ � -- (cammencing wah seEtror+IOFI�}e4 D�rfswrr 3 a4+he 6us+ness � ounETs oveu L ond Profe�i4�s Gvd�and rny:ti�ens�is en ful}fors�.satsd eHect �- 5 PER SrSi�a _ }..� � �.� ... _ VAttit7/i'f1�l� � s .. Li[ense Num6e� `� Li[.�Class�"'�r � .. - .��. �.�r��� . . . .V. � : � ��R� a � - � Contracror .. � -Dvte�+���� - . .._ . . BY.� _ . . . . -. .F . ,. ❑ .J�am exempt vader Sec � - . - _ - . w � . . . . . ._ . . . . _ . .. -G. � 6.8P.C.for th�s reason� - - - � . . �� . � . - � { P(an check fee � Z • — � . . :: oai�:. . . .. :. - . € � � - �� PLUtdrBtNG PERMkT t55UING ffE b � 1� ..r . � . Si rroturR . �� � 9 rara�F� - G 7 6 5 A � � �.. .. . .� � " �- � - Pfarr chec(c appf+mnt_. . - .-. SINGIE FAMI�W � �. � �-a s`] _ � HOMEOWNER-6UtlDER pEClARA716N Name - - - ��`t� ebyaEfsrmihotlamexempf4ramtheGontrnctor'st'rceFrse -. Address -.. -- ..- :__ ::.. _ :. ,=— ��-' � -=�- � "- ♦�aer�¢,,:�.�_ , . ="-� - �ow#or the#oltorring reason�{Seetztxt-T4Y.##.5,Bnsir�ess rmd - - � . _ . � Professions-Code):- � -- -- : � . . � C7ty - Tef.Na. - - � � � . .. . � G6i r=85 Q�:,l,as owner of the property,will do Rhe work aad fhe .. � .. . - . . . . . .shucture is not intended or offered for wle(Section _ . . - . � . - . -- - �, - 7Q44,Business ond Profeuions Code). . . . - . , . .. � -� � CONSTRUCTJON tENDWG AGENCY - .. . . � - �- - . . � --.� � - � - - . � . f hereby affirm fhat there is o eonstruction tending.agency for � � - . � - . � � � � the performanie�.of tfie work�for which this permik is issued . . . . . - . - . - - [Sec.'�47,C'rv:E.). - _ ' i �_- tender's Name . . � . ' . � . . ... - __ . . .,. . ... � . . � .. lender's Address �� . .. . .. - .. . . . � - . . � � � i certify ihnt I have�ead ihis applimtion and state fhat the - � _ � - - - nbove.snformatian is mrcect,1 ag�ee ta mmply with all County .: _ . . ordinartces and State laws-regulaiing Plumbing,and-hereby . . . �- - . . � _ outhorize representotives of this County to enfer upan ihe . � � - � � � - . . . � � oboye-mentioned property for i spection purposes. � . - - - _ . . . - - - SEE REYERSE FOR EXPLANATCRY LANGUAGE �- a.� �— -_ . . - � . _ �� _ . . - � - - - . � � Sig t of Permiltee . - Dote �... ........ .. ;� . . . . .. . . � . -� � . � � � . . - � . k�'.. . . . . . . . . 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