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0805A (4)
WORKERS'COM19PN;NSAT[ON�DECLARATION ]9A66]A ��PL��I=.YiTIC�N FC�rq P��JM�INq� PFR�IT �I t herebv affirm that I have a certR r.�nf snnsN_nr r��alf cr g,>��-nni _ _ � nu ire oc a certificaYe o£Wbrkers'Compensatiun[nsurancz,oc . . �_ � � a cert�Eted copy tfreraof(SeE.3800,Lab�.CJ � r�,�j,�Fs!,g'Z COUNTY OE LOS ANGELES BaJFCDffVG AND SAFETY -.Poticy No._ CompanY��.ETf�� � . . . . _ ... _ . _ . . . � _ ' {; y CertLfied capy is hereby Furnished. -� � e ; � ,.' ❑ � : FOR�APPUCANTTOF-I�LlN-iPRINTORTVPE) � ;,_Y=BUILDWG ��-. �� � � , - .. .__._ ___- AD-�RESS . ,,." .:; _ .; ; � � � Certified Copy i5 filed with the coURty building fn5pection NUMBER FIXTUFE OR ITEM � FEE . � E d�{ar�nt� et / � ' - �t �OCALITY �{�y �} j � ,6'� -%J . l��w �J , w�- WATER CLOSeT ......_ V-�T //�., _..-... �V/`f"�.✓�Y L>T� . �- } ; �Date ...,. -APPlicattEr _�1��.l�l .��.eS�� _.._:'y�'—___..___- -...___. _ __ i ,?' PJEAftEST �. f'J �. ., " 6ATH TUe CRO55 ST ���,�, C,r�BiFJ/�'j,F�p�:�.�. CERTITIC lTE OF fiXEMPTION FROM WORK�RS' " � - � - COMPENSATIONINSURANCE - j' SHOWER e OWNERry _ /a�- .-�'^ 1tt�%Y- `,� �� � �i90. . MAI L (Th3s section need not he ce�mpteted if ihe waik involved LAVATORY �;..._ Ao�aEss�a ��' g„P�iy,•,�,ep ,C�vr� 's�. '. � by the potmit ie for mie hundced doltars ($1tl0)ox less.) s' � SiNK Q•� � CITY l..NO. �y . , - --- ��ar..� , .� ,+t',er.3 �"�l��3�3' i I ecrtify that in the pacformance of the work fo[whieh this �C�iSHWASHER 1..:' - �-permit is issued,I�shall�nvt-employ any�person in any manner � ! CONTRACTOR ��. � . � �._ ; � so as to Ueco�tte subject to the Workers'Cnmpensation Laws. , �CLOTHES WASHER I ADO�RESS' ' ��✓J � ' f !�� - f.�� o �, tr•.. , # Date Applicant , ry� ; � r ._ .. .. .. .. . . . .�_.:..�:.. -S+NdMhAlNG-PDt}L�-REGEFT6Ft I . ._... a. � - ;: � NOTICE TO APYLLCAN7' U�,afYer m2king Yhis Ceri�ficate of --t- , CITY���.����� TEL.NO��,���� e9�-.- � Exemption, you should oecome subjec( t� the Workers' LAV4NSPRINKLERSYSTEM i " �;; , . : � �Cum ensation isions of the Labor Code, - -- --- --- - ' �7 y J c y p pruv you must r�rfh- WATER HEATER -..�— �, j L:CE S�E NOfi����„s/ LI PSS� `�C'-�� ::� ; � wi�h comply with such provisions or this perm'tt sliall be � j deemed€evaked. � i T �,—' DISTRICT NQ. PRC}2.ES5EQ eV cASSVSTE(vt OUT�ElS i_ � - LFCEnSED CO�TTRACTORS DEGLARATION OUTLETS OVER —�—� i �� �,�.�,.)ye. _ � 1 hcreby aff'vm thaY I am iictnszd u�nder grovisians of Chapter 5 PER SYSTEM � i � 3�(commenrng w'sth Sectioa 7000j of DivisSon 3 of the Busi- - �` "' ' FiNA� VALIDATION ^ ` � ness and Profassions Code,and mp license is m full force and �• ��r'��t�L��'_i�?e1.wt.eT"a i r' �i��� DATE '�-Z-- �j i; effect. � . . 5_ � ,e�, ,y� . ,/ ���j� , _. ......—_ FINAL Licenne Numbe6�'�+'�� Lic.L"lass ��G�" 7' r.+� � BY � � �_ ,�i �° ({/� �d • ,��'j�-n #� " � — _ — �1 � . Contractod` ._'��pl_� Date_" �f�--.�P°+ ud .�,7 . � . ,: � '___'__ _ , _� . � � I am exempt from ffie licensing requirements as[am a ,P�a�1 Ch2Ck fe@ -- �- � 3icensed arciiitect or a reg�steeed professional engineer -FL'UMBiNG FERM14 tSSUING FEE$ � - � acting in my pruiessioaat capacity (Section 7051, Sus- . r �� iness and Yrofession�Code). . . ��� r^� , ,, T�7AL FEE 3 �. � Lic.or Reg.No. Date � plan ch�ni „ g � y �,s � '�Name . � �� �. HObSH OWNER-BUILUF.R DF;CLAR,aTION �. �-�, 5 hercby aFficm tltat I aia exempt from ft�e Contractor's �- �ddress � s s � , :'�;�� ° s ( Lscensc Law for the foilowing reason (Section 7031.5,Busi- ' City Tel.No. : r f'..r �., �. �' ness and Yrofessions Code): - �� - „�� � l,as uwner of the property,am exciusively contracting � - - , ;�" � with licensed eontraetors Co constract the project _- Q%r"� :e.t (Section 704a,Business and Profess�ons Code). •, - � ��¢. CONSTRUCTION LENDING AUENCY " � �$y� � I herei�y aFfirm that there is.a wnstru�tion lendmg agency ����� ':� �- � ' �-' ' "" `" ''"^ for the pexfnrmance nf the work �br which this permit ie qiasued{See.-3097,Clm:�.). �. � . . _ - ���'� Lende�'s Name - � -�� �� :,,��t. -� Lender's Addre;s _ _ '� � � �.. � I certify that I have read this application and state that t0e . . _ .,;�; above infocmation is mrrect.]agrae io mmply with all County SEE REVERSl POR EXPLANATORY LANGUAGE "° i' � ordjrtances.and State taws.regulating Plumbing, and hercby _ � ,, �, � authorize representativas of this County to enter upon the - � � a -mentioned property foL inspection urposes. �., � ' . . . .. . . -; •- _ :, ; J , � c� � ,���'��°'�� ���gl� - .� � ��� � � ignature of Permittse D _ y rt,i ._N .F .H ,V..,..TM ' ,Y i tl.�4.. ` �.. �:t ; m c;n ���'�c�l�'�c�"� ��'�'do _ I D i �im�plb .nl� i1i��n �z i �D � o z ��n I�� , � . � � Iz � � �� I. 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